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FOR OFFICE USE: .� ----------------------------------- ---------- APPLICATION FOR SANITATION PERMIT Permit No. ..,�.f� .��'� --------------------------------------------------------- (Complete in Duplicate) ------------------------- This Permit Expires 1 Year From Date Issued Date Issued _-... ..l.. ._l 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----------- Z c' ---------------------------------------------- . ------ Owner's Name------------------------ —----------------- d � v .fi - � Address...............•••.......................A5--/-----7--r-----------------Z5------------------ ---------------------------•----•--•----•----•------------------ Contractor's Name---------------------------------------------------—5. --------------------........•......------------------- Phone-•-•............................... Installation will serve: Residence Z Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/--- Number of bedrooms _-'2,.–Number of baths ------/Lot size -......... ---------.- Water Supply: Public system E,_�Communify system ❑ Private ❑ Depth to Water Table 7-_47ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date----------- --------1 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.) Septic Tank: Distance from nearest well_-_-.---- -.--_Distance from foundation____,e1__s?--__-_.Material......... _ ... _ _ .. xNo. of compartments.-------------1__,_.._Size_____- ,Y _,A.,�.`_Liquid depth--------I`.l,.--------------Capacity.......4r??A.--. Disposal Field: Distance from nearest well---P�-----Distance from foundation-___--- Distance to nearest lot line....X.4'.... Number of lines-----------------� .----------Length of each line------.------- Width of french...........R�---------------- Type of filter material.._. –c,,,C___Depfh of filter material.....e!'----..-total length............f..�_�?..____.-__-. 4 Seepage Pit: Distance to nearest well-t---- --.---.--Distance from foundation....................Distance to nearest lot line................. Q ❑ Number of pits---------------t-----Lining material............-----------Size: Diameter---------.--------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----.-----.-_---------------_----_-__ El Size: Diameter--------------------------------.---.-Depth -------- I---------------------•---------..Liquid Capacity _ -gals. Privy: Distance from nearest w Privy: '_-- Distance from nearest building----------------------------------------- . ❑ Distance to nearest lot`line--------- --------------------------------------............................................................----_------------------------ Remodeling and be): Sl( ------1 -•---••.... •- •-••-•---- ----------- -------------- ."` •------------ ---•----- -----------------•.---------...-------.....-----------------....------------- .......................---------------•-----------t_----------------..-------------------------------------.----.-.----.._._.------------------- _______ I _ _ _ I hereby certify that I have prepared Phist application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. t�t , (Sign$i --.. __.... ed) . -------------------------------------------------------- ------.-_.(Owner and/or Contractor) BY: ----••-------------------------------------(Title)---------------------------------------- ----- -- ----------- (Plot plan, showing size of lot, location of system in relation,to wells, buildings, etc., can be placed on reverse side). R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- '? ---------------------------------------, ---•------•----•---•-------•-•- DATE-------- o; 6 _3-------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------ ... DATE------•------------- BUILDING PERMIT ISSUED........................ { D,4TE - ---------------------- Alterations and/or recomme dations;. - �.. __ - ----------------------------- - -- ---------------------------------••-•---•---•---...-------...-----------------------------•---•------ �� -- ------------------------------------------------- ---------- ------- -- ---------------------- FINAL INSPECTION --------------------FINALINSPECTION BY:-------------------------------------------------- ------ Date------------------------------------------- ------ ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 134 Sycamore Street 305 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ro 9 REV$SEo G-99 2M 5-61 ATLAS