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FOROFFICE USE/ ------ ----)--------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. --- -----------------•---- -- --------------------------- (Complete in Duplicate) --------- This Permit Expires 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 Ordinance No. 549. JOB ADDRESS AND L C -------------------- --------- -- --- --- • - -- �•�C4�-• ----- -- -- -----"---� ---------- ----Ph. - Owner's Name........ r . Address........................ Contractor ddress----------------------- Contractor s Name . . .(r - Ph A",--•-•• / ' y Installation will serve: Residence artment Hous Commercial ❑ Trailer Court N40tel ❑ Other ❑ Number of living units: _ ____ Number of bedro 1 _____• Number of baths ____._.. Lot size -_._...... Water Supply: Public system ❑ Community system ❑ Private*_Depth to Water Tablft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ New Construction. Yes ❑ NFHA/VA: Yes ❑ No ❑ ENLATION AND SPECIFICATIONS: ✓� tank or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well_________________Distance from foundation_______..______.__.Material--------------------............................. No. of compartments--------------- ---•-- --Size-----•--------------------------Liquid depth--------------------------Capacity....................... Distance from nearest well--- Distance from foundat/i�o.n____1J�___Distance to nearest I t line.---- Number of lines-----I____ ___ _______ ____Length of each line-_-0-10 ______ Width of trench____. .f.. Type of filter material.w _ -'.-.Depth of filter materi�___1_f.._�.._Total length_---------------------- A19 ________________�_._ .�_.__.. Distance to nearest well--- Distance from foundation...._.• ._ epag I ,� ..__..Distance to nearest lot line... _...... Number of pits-----/---------------Lining mate rial,R` -------Size- Diameter...Z..��--____Depth____ _ ___..._...._..._. Cesspool: Distance from nearest well-----------------Distance from oundation--------------.___..Lining material--.-----____-_________________.._..-_ ❑ Size: Diameter.---•---------------------------------Depth----------------------------------------------------Liquid Capacity---------•--•---------------gals . Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.._.___.________________-_•--__-__-_____. ❑ Distance to nearest lot line------------------------------------------------••-------------------•---------------•----•----------•---------------------------------------- Remodeling and/or repairing (describe)_____________________ _ _07'fr 7n.---------------------- o ------------------------------ --------------••------•---------•---•--•• --- ------------------------ --- -----•---.....----------------------------------------------- -----•-----------------------••--------------------------------------------------------------------------------------------------................. ---------------------------------------------------------------- ------•-- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a la s, a ul end gul tions of t Sa Joaquin Loc ealth District. _ _._ �� (Signed) •• ontractorl i By:..........................................------------_ ------------- --- --•- ---�--•---------(T't+le)----•--••---•------------------------------------ -------------- (Plot plan, showing size of lot, location of system'in relaf to wells, buildi�s, etc., can be pieced onCZ reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCE=PTED BY----- J_-�--- -- -- ------------------------•-----------•---- DATE----Z;---- REVIEWEDBY------------------------------------------ ------------•--------•------------•-----------------------------------•--•• DATE---------- BUILDINGPERMIT ISSUED-----•----------------------------------------------------------------------------------------------• DATE--------.-..----•-------------------------------------------- Afterations and or recommendations__________________ . -------•------------------------------------------.....-----------------------------------------------------------------------------------------------------------------•-----------..._.----------------------------------- FINAL INSPECTION BY: Ef -- - ----- Date--------- :` C �� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 0 REVISED 8•89 2M 8-61 ATLAS