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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .. ....1..... --------------- ------- -- ----- (Complete in Duplicate) ' This Permit Ex ires 1 Year From Date Issued Date Issued ............. ....... Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordina�ntce No. 549. e-%.IZ JOB ADDRESS AND LOCATION .... °"__ ------- __--------�� Y Owner's Name------- ------------- --- -- -----• Phone.................................... Add ------- ....&-m`h'o.--•-- .................. ............................................................ , h Contractor's Name.,„ ,/�,�/_Q._...s. _.__7P_�l_-.-------•-•-- ...... Phone................. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j____ Number of bedrooms _-_- Number of baths _,5___ Lot size JxI -x.f Afr-•-•........................ Water Supply: Public system ❑ ComMunity system ❑ Private [Depth to Water Table J--o— ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay dobe❑ Hardpan ❑ Previous Application Made: Ilf yes,date___________________) No [ New Construction: Yes URI"No ❑ FHA/VA: Yes UE�-'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Cdr (No septic tank or cesspool permitted:if public sewer is available within 200 feet.) i t Septic Tank: Distance from nearest wel(c6_0__.*'..Distance from foundation----/ ....._.._.Material_____`______________ _______________________•_-. [ / $/ • _Capacity.. Na. of compartments- ----------- depth__-__-- ----------____-- 1.;.�:Da� 00 Disposal Field: Distance from nearest well..,.'i__Q___i-Distance from foundation...1 4______.____Distance to nearest lot line......_...... Number of lines-------_--_1• --- --------------Length of each line-------7%T-- ------.Width of trench...... ('-•,.---------------- Type of filter material-_-_!C_?_�_�------Depth of filter material------ _ __-------Total length-------/b` -__ _ _•--_- r r Seepage Pit: Distance to nearest n well__��___-________Distance m foundation__..:�v.....__..Distance to nearest lot line_ Number of pits......L- --_------ g � .._Size: Diameter------- � ----Depth-------------_�eZ Linin material____ / -Q-G_ ._.__..•......... Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- 0 Size: Diameter--------------------------------------Depth----•-----------------------------------------------Liquid Capacity---------------------------gals. (� Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line--------------------------------------------------------------------------•--------------•--------•-------------•---------------------•---- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- - -------------------------------•--•---••--------•--•--------------------------------...---------------------------------------------------•-----------------------•----------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regula ' ns o the San Joaquin Local Health District. (Signed) (Owner and/or Contractor) By:.-•---------••-•-------•----•---- ... ... ................ . .. ---------------•--•-------------------------(riifle)----------------------------------------------- ---------------- (Plot plan, showing size of lot, location of system in re tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ----- - -------------------------------- DATE - REVIEWED ATE REVIEWED BY ------------------ ---- - --------------- DATE-------._._.....-------------------------------•------------ BUILDING PERMIT ISSUED............----------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:----C-------%� ---------------•---------------- Date--- -------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 205 West 9th Street e Stockton,California Lodi,California Manteca,California Tracy,California - E6 9 REVISED 8-89 2M 5-61 ATLAS