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FOR Of E U E: v � r .____........... :.........___-._.-_--.------------.-. APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------------------ -- (Complete in Duplicate} ..:. ..._..�._ ��- '---------------------------------------------------------- This Permit Expires 1 Year From Date IssuedDate 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. JOBADDRESS AND LOCATION----- ®. ....... f'��-�--•--. . -----.......R..................................................................................... Owner's Name 6 ......-_•---•-----•----------- -----------------------------------------•----- Phone............................... Address- ---.................................................................................................. Contractor's Name. - ."'. ---- --------------- f ---- ---- - - -----•--- Phone Installation will serve: Residence E�<partment House ❑ Commercial-1❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ----- Number of-bedrooms ..,Number of baths .l._ Lot size ............................... I Water Supply: Public system ❑ ;Community system ❑ Private�[e�ep+h±fo.Water Table _.ZDft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy, Loa'm ❑ 1,Clay Loam ❑ Clay ❑ Adobe[3-hardpan ❑ PreviousApplicationMade: (If yes,date-.------ ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _ S Se t- Tank-,, 1 I jank:� Distance from nearest well.................Distance from foundation.-...____._._.-_...'Material-..-....-......._._............................. til; No. of compartments--------------------------Size--------------------------------Liquid depth-------;�----------------Capacity....................... D osak Field: Number lines well.... + --: Length ofDistance rom eacFl line -�-�'a--:1DNistdance to nearest I line../ ~ p ,/ foundation �� k � th of french---�----�..................... �, Type of filter mate riaLl �/�B Depth of filter material____. _'__.-Totat length------ I.�.......................... Seepage Pit: Distance to nearest well................. ..Distance from foundation....................Distance to nearest lot line--------.___----- ❑ Number of pits---------------------Lining material'----=-----------------Size: Diameter------:,�--------------,Depth-------------------.----------_-- Q Cesspool: Distance from nearest well.................Distance from foundation------------.-------Lining material--------------------.___..--------_-. Size: Diameter---------------------- ---De'fih----------------------------------------------------- !I quid Capacity .. ❑ ------------- p, �q P tY---------- ---...-_...._.._gals. Privy: Distance from nearest well.................................................Distance from nearest building------------------------------------------ F1 Distance ......._.-__....__---------. --------- Disfiance to nearest lot line. ----------------- --- ----•. ...------ ----- Remodeling and/or repairing (describe):---------------------- ...................... ..............................................................-----------•--------.----------------------- ----------•---•- -- ------••--------•-•-----.14 ..... A 1 ----•-•----------•-----------------•-----------------......------------------------------------------------------------------------------------------------------------------------------- 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, and rules pnd regulations o the San Joaquin Local Health District. { (Signed)-•-•------- -------------- ------`---------- --- -------------------- - r------ (Owner and/or Contractor) By:----------..........---------------------------------------------- - ----------- ------- --- --- --------(Title)---- --------------- -------- -------- (Plot plan, showing size of lot, location of system in relation o ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY + i APPLICATION ACCEPTED BY-- S - - - ----- ----------•----••-------------------- DATE REVIEWEDBY----------------------------------------------------------------------- --------------------------------------------•-...... DATE....-----..............................I..................... ' BUILDING PERMIT ISSUED------.......................... ...---.......---•---------------------------------------- DATE-----------------------_---------------- --------------- Alterations •-------------- 'Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------•-•---------------•------------------------------------ -•-•--------------------------------------------------------------------------------------------------------------------------------•---...---•-----------------------•--....:-....... ---------------------------------------------------.....-•-----•----•-•----------------------------------------------------------------------------------------------------------------•--- -------------------------------- FINAL 1 PECTION BY:-.a /-.L..d-------- Date �1� .-I��.lr�------------- l SAN JOAQUIN LOCAL HEALTH DISTRIC 130 South American Street 300 West Oak Sr►eet f 114 Sycamore street 205 West 9th Street Stockton;California Lodi,California • } 14lanteia`.Californla Tracy,California ES 9 REVISED 6-s5i EM 5-61 ATLAS s r