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FOROFFICE U59� ,,-.--.--t; -----______-_- .... APPLICATION FOR SANITATION PERMIT Permit No. - (Complete in Duplicate) y -- ------------------ ------------ This Permit Expires 1 Year From Date Issued Data Issued4... --- 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 LOCATION----- ----•------zS ---------------------------- ,�-Z_ .Owner's Name-------------- ----------• __.- Phone./ e_ Address -L ---------------------------- •-•-- Contractor's Name...------ . ____..__.__y Phone. . . �--c� . , Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer CourtX Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ..................................................... Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe , Hardpan ❑ Previous Application Made: (If yes,date--------------------) No;K New Construction: Yes ❑ No)�L FHA/VA: Yes ❑ No,K TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SP tic atilt: Distance from nearest well_________________Distance from foundation....................Material................................................. Q l No. of compartments--------------------------Size------•---•---------------------Liquid depth--------------------------Capacity....................... I " �Disposa 'gield: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- or— Number of lines-----------------------------------Length of each line--------------_---.-.-.----.Width of french___..____.._._...............__.... Type of filter material-------------------------Depth of filter material-------------------.•-.Total length................__....._.__.________ ..__ Seepage Pit: Distance to nearest well_ -x.Q.,----Distance from fun ation___-- D__ _.Distance to nearest lot ...... Number of pits-----------I--------Lining materi4>1111�_ Size: Diameter._.._$.` Depth ------------ ? Cesspool: Distance from nearest well.................Distance from foundation....................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):---- _ _ _-- ---- -•• --• - _ ---_ ------------------------------- -------------.......•................--------------------------------------------------------L/----------------- -- -----r•--•-•-- --------------------------------------------------------- ------------------------------------------------------•------•-•--•----.----------------------------------------------------------------------------------- -- ,r --------•------••-------•-------•-••----------------------------------•---------------------------•---------------------------•-••-----•-•--------•-•--------•---•--•-------._-------------------------•- t' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, antrules and regulations of the San Joaquin Local Health District. (signed) nV ........... � L __.--.-_.(Owner and/oror Contractor- --� By: --- -------------------------------------------------- ---------------------------------------- •---_---_-------------------(Title)-------------------------------------------- ------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1,2 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -,+ ----------------------------- DATE-------- --------------------- REVIEWEDBY------------------------------ •-----------------------------------------------------------------------------------------. DATE------ ----._...-----••-----•--•--••----•---------•---- BUILDING PERMIT ISSUED d� ----- -- DATE - - ----------------------------------- -------•---------- ------------------- - -- ------ Alterations and/or recommendation - . - -- ------ ------------------------------------------------------------------------- -.---------- .._.........--- -•---- -- •--••--- ---- _ 1 f fi :.. - - - - _ ... ...........-.. . FINAL INSPECTION BY:\------- ---- ----------- --------_ Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strout y 300 West Oak Strout 124 Sycamore Street 205 West 9th Strout Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-S9 21A a^61 ATLAS