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FOR OFFJC USE: 1 __ _.... ---------- ------------------ APPLICATION FOR SANITATION PERMIT Permit No. .... ---- -------- ----------------------------------------- (Complete in Duplicate) Date Issued - -------------------- This Permit Expires l Year From 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. ('73 - f'70--Q�- Wpb F,_�-Ct 447�( ST - / JOB ADDRESS AND LOCATION. a ^�.._......... --------------------------------------------- Owner's Name------� �"1` --------------------------- Phone.................................... Address------------ i�s.�----- .............•--...--------•------------•-------•-----••--------•-•-------..--------------•---•------------•---------•------•------••----•--•-- Contractor's Name- - --.-�-•----- -------------------------------------------•----- ........................................I.... Phone................................... Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----/__ Number of bedrooms • Number of baths .-.I___ Lot size ._ V_-4t._ ........................... Water Supply: Public system 0--c-ommunity system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe EI'lHardpan ❑ 'Previous Application Made: (If yes,date____________________) No 9?`� New Construction: Yes [6'-No ❑ FHA/VA-. Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 2DO feet.) 'Septic Tank: Distance from nearest well__Distance from foundation___1P_... ------Material___________� .. No. of compartments.._2-________________Size____---:�. b__X ......Liquid depth.__ __.`------------Capacity �' Disposal Field: Distance from nearest well-!lrtrf�! ___Distance from foundation-.1Q__.___.____Distance to nearest lot line ............. t [� Number of lines----------------:-L ------------Length of each line____ `-__--_-.-_.Width of trench______4:L.'................. Type of filter material. -------Depth of filter material_=_/'total length......... '_.rSP_____..__-- C �i N Seepage Pit: Distance to nearest- ell-_�'!'-1______Distance fr ?foundation__ A....._....Distance to nearest lot line S-._______-- Number of -------Lining material----_._�J1. ,' Size: Diameter.----- - -`----..Depth- I!r est well Cesspool: Distance from ne r p a a -----------------Distance from foundation....................Lining material..-__._.--__--.•----••--.---•........ ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------.Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------_-------_------Distance from nearest building.......................................... ❑ Distance to nearest lot line----------------------------------------------------------------------- •---•--•---••---------------------------•---•-----------•-------- Remodelingand/or repairing (describe):---------------------------------------------------------------------•-•------•-•--------------•-----------------------------------------••---•-------• ------•----------------------•-----------------------•------•-----------•----------•-•----•-----------------------------------------------------------------------..................................•-....................... 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 and regulations f the San Joaquin Local Health District. (Signed)................................................. ---------- ------...---- ---------------------•-------------------------------------------.....(Owner and/or Contractor) By:........................• --------•-------- Title -------------------------------------------- , - --------------------- -------------- (Plot plan, showing size of lot, location o sys in relatio to wells, buildings, etc., can be placed on reverse side). FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY..--- E - - - ---- - - -------------------------------------------- DATE---S- _1_7 REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------ - - ---- --- ---- -- --------•-••----------------------------------------- DATE------------------------ Alterations and/or rec mmend'atio s______________.___-_ .__ - -- �_. .....f... ...................... -------------- --------•--...--•-•------- -� - ------------------•------ FINAL INSPECTION BY:..... .- --- -_--------- -_ Date..-- Z SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak S"oet 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 RM E-61 ATLAS .r_'rt