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VUK UFFICE USE: --------------- ------------ --------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .., 5-.�/.l_�� --- ----------------------------------------------------- (Complete in Duplicate) f/ ------------------"------------------ ----- 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 A LOCATI N - r Owner's Name_.. _--- Phon Address.......... , ._ Contractor's Name___ _-_ •_ _-•- - - ,.. Phon '� Installation will serve: Residence Apa ment House ❑ Commercial ❑ Trailer//Court ❑ Motel ❑ Other ❑ Number of livingunits: __ Number of bedrooms - Number of baths ._/-- Lot size _/ Water Supply: Public system ❑ Community system ❑ Private Depth"To Water Table U_ ft. Character of soil to a depth of 3 feet: Send E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date--------------- ___) NoNew Construction: Yeso❑ FHA/VA: Yes ❑ No [��_- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well_________________Distance from foundation--------------------Material----------------------------------------......... �,.c.- No. of compartments -------------Size---------------------- Liquid depth --------------Capacity Dispos eld: Distance from nearest well-----------------Distance from foundation__________________-Distance to nearest lot line............ Q �•�" Number of lines------------------- ----------------Length of each line Width of trench. Type of filter material-------------------------Depth of filter material---------------------- length_--____...______----____. eepage Pit: Distance to nearest well__ , ,' - ----•_-Distance from fondation__l�---------Distance to nearest lot line--- �6_~_".---_ Number of pits..... -------------Lining materia ^- -------Size: Diameter__P.;V9f------Depth.--- Z— `--------------- Cesspool: Distance from nearest well----------------- from foundation....___._________tiLiniing material_-_.____----_______.___-.._ Size: Diameter.-----•-------------------------------Depth--------------------------------- ----- ---- - ----. a _Liquid Cpacity-_--•----------•--- --gals. ---- rivy: Distance from nearest well---- -----.-Distance from nearest building ❑ Distance to nearest lot fine----- - ----------------- ------------ - -----------------•-••------------•-- Remod an or repairing (describe):--- ----`----------- - --------------- / * ---------------------------------------------------------------------------2�7-------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I---------------------------- -----------------------------*----------------------------------------------------------------------------------------------------*--------------------------*-------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County ordinances, State laws, and r les d regul ions the S Joaquin Local Health District. {Signed}. -------------------------------------(Owner and/or Contractor) - {Title} 4 . (Plot plan, s ' e of to ocation of system in relation to wells, buildings, etc., can be p a ed on ever t e]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1 � DATE.J17n. (T` ------------------ REVIEWED BY-------------------------------------- -----"---------------------------------- ----- DATE-------- -._._ BUILDING PERMIT ISSUED--_------------ Alterations and/or recommendationsz.__________________ FINAL INSPECTION BY:.-- .�- c ---------_--- Dete )4� ��- ' '-------------------------------------------------- SAN --------------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 SouTh American Street 300 West Oak Srroot 124 Sycamore Street t Stockton,California a Lodi,California Manteca,California Tracy,California E5 9 REVISED B-59 2M 5-62 ATLAS