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rTOR OFFICE USE: . --- - . -------------------- APPLICATION MR SANITATION PERMIT Permit No. ... ._. .............. -----------------•----------------------------------- (Complete in Duplicatel ! 1 --------------- I This Permit Expires I Year From Date Issued Date Issued ------�fi 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. S49. / JOB ADDRESS AND LOCATION......... . ...... e-- - ------------------------------------------------•------------------------------------------- :a Owner's Name........ - •-- - _ - ••--- .. Phone.... -p Address.............J='-K�f J,.5-K43------- ..... - - ----------------------------------------I------------------------------------- ......................................................... ¢ Contractor's Name..------` '--��_.. f ..... ? ..... ------------------------------------------------.......... Phone................................... Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms .A7- Number of baths ---I--- Lot size ...... Water Supply: Public system W Community system ❑ Private 0 Depth to Water Table -------- ft. I I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam M Clay 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.) i Sept' Tank: Distance from nearest well---_-______Distance from foundation---.111______-- Materi l__6�_._ ._ __ ...._... No. of compartments_______ ----------------Size-..._1__75._��1___Liquid depth__..._.--------------capacity---� ..al'— Disposal Field: Distance from nearest well---- Distance from foundation... ......Distance to nearest lot line._-�...... Number of lines_______.__`_--_____ --------Length of each line--------jti�).______.._.Width of trench....... .................. Type of filter material._ _ .. '� yp .� __,.---.Depth of filter material.------ length_______ ___ ___________ Seepage Pit: Distance to nearest well---------------_------Distance from foundation--------------------Distance to nearest lot line..__._________-- 0 r ❑ Number of pits----------------------Lining material_------------------._Size: Diameter-----------------------Depth-- .--------------------------. t Cesspool: Distance from nearest well-----------------Distance from foundation------- -- -_------ rnng material------------------------- El Size: Diameter-------------- ----------------------Depth_------------- --- Lqidmapacity----------------------------gals. � '. Privy: Distance from nearest well_________________________________________ _______Distance from nearest build ing.____.__---_---------_------------------- --- � ❑ Distance to nearest lot line Remodeling and/or repairing (describe):----------------------------------------------------••--------•------------•---•---------_--•-•-•----• - •----------------•--------••-•-•---------------------------------•------------•-•-••--•---------.-.-------•-------------------------•-•---------------------------...-----••--•--••---••------------•------------------------ ------•---------------------------------------------------•--------------------------------.--•-----------------------------------------------------------------------------------•••------------------•--------------------- hereby certify that I have prepared this 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. - f4 (Signed . ........ _____.___-(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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------- --------- -- ---------------------------------------------------- DATE--------- . REVIEWEDBY------------------------------------------ - ----------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED------------------------_-------------------------------------—•---.--------------------------------- DATE-----------------------•-••------- XL erations and/or recommendations:-------------- ----------- --------------------------------------------------•---------------------------------- ............. -- ------------ FINAL INSPECTION BY:___ __ ... ._ - S� Date.-- . SAN JOAQUIN LOCAL HEALTH DISTRICT f 130 South American Street 300 West Oak STreet 124 Sycamore Street 205 Wast 9th Strut 1 Stockton,California Lodi,California Manteca,California Tracyr California } E8'4 REVISED 8-99 2M a-E1 ATLAS