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r .. '--- -._ -FOR f .....'- ---------------- APPLICATION FOR SANITATION PERMIT Permit No. . .. -------------------- ---------------------------------- (Complete in Duplicate) -------------------- This Permit Ex ices 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 mode in compliance with County Ordinance No. 549. JOB ADDRESS ANDA ATION...__ .: �1. 3Owner's Name_______ f�__---e. _ -------------------•---------- --------- ------------------------------------------- Phone.................................... Address-----'..... t Contractor's Name----- ----..... ------- ----------------------------------------------------- ------------------- Phone................................... Installation will serve: Residence ❑ Apartment House E] Commercial F] Trailer Court tel ❑ Other ❑ i Number of living units: . -..... Number of bedrooms .f--- Number of baths _Z__ Lot size� __�� _______________________________ 'Water Supply: Public system ❑ Community system ❑ Private QlDepth TO Water Table . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 Senk: Distance from nearest we 1__ ____..Distance from foundation---_I—_____._.M a torial...L�r_��__A'!? ______________. No. of compartments___ _______________.__Sizes>,!- '-�.4.:__.Liquid depth---��-----------Capacity..,r ------------ V ._- Disposal Field: Distance from nearest well. ;�P__---. Distance from foundatio ...r _____---Distance to nearest lot line.-,.�~....... Number of lines.........-__ ._ Length of each line____��_____-___-.Width of trench__ 7---- -- .- - ------------ Type of filter material.. /.__ _ - ._.Depth of filter material.-__.`c!Q"______Total length..----crf,-_�______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line______________.-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------._.-.•----------Depth--------------.---..------..---_. Cesspool: Distance from nearest well ..............Distance from foundation-----.--------------Lining material..----------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity.-.-------------------------gals. Privy: Distance from nearest well________________________________________-------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line-- ------ ----------------------------------------- ................------------------•-----...---------------------------------•-------- Remodeling and/or r pairing (describe):------ �----- � ....... '--- ------- ------------------ ` ----- hereby certify that I have pre ared +his applica+ion and that th r will be done in accordance with San Joaquin County ordinances, State laws, and r s and regulations of the San Joaquin Local Health District. 2(Signed)----------------- --- --- -; ------------ ( �`Coctor - --- v I By:---------- .......--------------------------------------------------- --------- (r+lel " (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- - --- -------------------------------------------------- DATE------ ` REVIEWEDBY---------------------------------- '-- -•--- ------------------------------------------------------------ DATE------------------------------------------------------- BUILDINGPERMIT ISSUED------------------_-------_------------- ----------------•---•-•--------------------------------- DATE---------.---------------------------------------------- . Alterations a d/or recommendations:.-__.__________________________ ____ _______________ ___________________ _ f ✓---- ------�-- --------.--- , __ - ,z -� -- , - -------- -•- --------- - = --------------------------------- - = FINAL INSPECTION BY: - Date-------y�Lr ------- ----- ------------------------- 11 ' ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strut 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 f1EVISEO a-59 2M 5-62 ATLAS A L