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FOR OFFICE USE: _ .— _ p -�-- APPLICATION FOR SANITATION PERMIT Permit No. ---=----- ----------- ------------------------------------------- (Complete in Duplicate) Date issued .1 �. _ —.:.("�� _--._--,-------_---------------------------------------- � This Permit Ex ires 1 Year From Date Issued __.. .. .. Application is hereby made to the Sar- 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 _ _ _ _ ----------.,----- -----------•--•----------------•--•---------------•--------------------------- Name _LL�1.. y ------------------------------ Address-.-. -------------- Owner'sPhone. 4 +7� f --- Address............ .11-p- -• - ^...---_------------------------------------•----------•-•------------------------------------------------------------------------------------------- Contractor's Name-------- ..1/... -------•-----•--------•------ Phone-------•--------------------------- '' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [Ir , Number of living units: ...___ Number of bedrooms ---2— Number of baths __I____ Lot size ... Water .........:....................... Water Supply: Public systemErtommunity system ❑ Private F1Depth To Water Table __ik?ft. Character of soil to a depth of 3 feet: Sand [-] Gravel ❑ Sandy Loam ❑ Clay Loam [I Clay E] Adobe[Hardpan ❑ Previous Application Made: (If yes,d'ote---------_----------) No [ "New Construction: Yes [rNo [IFHA/VA-. Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pe"mitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well------ --__Distance from foundation.f_p------------Material- J. No. of compartments_.___ -- ....................................___._.. Size id dh----------------------Capacity--•• .�"�°;r� �'X 'r ------Liqudepth Disposal Field: Distance from nearest well------------Distance from foundation=- ............Distance to nearest lot line-bT=_�........ ; Number of lines: •- --------------- --Length of each line-----�------.-------------Width of trench-------Zl1_�!_-.-------------- Type of filter material.-jZv&.t�t______-__Depth of filter material.�G�_� Total length___-___7a___________________________ Seepage Pit: Distance to nearest well----_` ---------Distance from found at ion_.��_.`.._.__-__. istance to nearest lot line_0r______-_ --Lining material__�c__4------- ize: ameer-----------------------.Depth------=_,'r�s1`-�-------------- �. Number of pits-_______�------ - - SDit _ I Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___..._-____-_._____________________ ❑ Size: Diameter. ------Depth---•------------------------------------------------Liquid Capacity. ------------------ •.-gals. ----------- II Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildinq-------------------------------- ---------- r ❑ Distance to nearest lot line---------------------------- ------------------•---------•------------•--------------------------••-------•------- I Remodeling and/or repairing (describe):---------------- - -•--------------------------------- ---------•--------•---------------------- ----••-----------•---------••-------------------•------- i ----_ --- ----------------------•--•--------•-----------• ------------------•------.....------•-•----------------------- i -•--------------------------------------------------------------- --- hereby certify that I have prepared this application a that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of e S Joaquin Local Health District. (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). �Olk DEPARTMENT USE ONLY { APPLICATION ACCEPTED BY l -------- DATE_.. = REVIEWEDBY------------------------- i - -------------------------- -----------------------------------••------------ DATE.----.-. --••---- ------------------• ------------------- BUILDINGPERMIT ISSUED--------------'_....- -- -------------------•------- DATE------------------------------------------------------------- Alterations and/or recommend'tions:----•------------- --------------------••------••----••--------•-------------------------------------- iI ------------------------------------------------------------ -------------------------------------------------------------�---------•-----------------------------------•----------- --------------- -----•--------------------------------- -------------- ---------------------------- -----------------------------...... l -----------------------------------•-----••-•---------- -------------------------------- I ---------------------------------------•----------------------...------ r--7 cr FINAL INSPECTION BY:. :] ------------------ Date------------------�^--------- -----{�--- SAN UIN LOCAL HEALTH DISTRICT 130 South American street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8.59 ZIA 5-6t ATLAS I -