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FOR OFFICE IJSEz -..__.._____ ________________________ _ _____ APPLICATION FOR SANITATION PERMIT Permit No. ...... f 2- '----------------------------------- --- (Complete in Duplicate) i ��z // ------------------------------------------------------ -- This Permit Expires 1 Year From Date Issued Date Issued .__'�:.�t...�4a 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.�- / �6-------- -------------------------•-------------------•-----------------_...... 1----------------•------------ Owner's Name...... ------- --------------•---- -----------------•----- Phone....... -------------------- Address.......... -------- -------•--Address__..------ZZ .....--.. ----------------------------------------------------------------------•-----•_..---------------------------•--• Contractor's Name...... .. _ --------------------------------- Phone................................... Installation will serve: Residence ,®—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: - Number of bedrooms - , Number of baths __l___ Lot size .... � Water Supply: Public system (Community system ❑ Private ❑ Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ 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.) Septic Ta~nkk:- Distance from nearest well_________________Distance from foundation._.____..._.___..__.Material................................................. No. of compartments--- ,,---/-----------Size--------------------------------Liquid depth------------------ -------Capacity------------•--•------- Disposal Fie Distance from nearest well_16 Distance from foundation....el ........Distance to nearest lot ine..s......... 0__" Number of lines----------------�---------------Length of each line------------------------------Width of trench._. ________ ---------------- Type of filter material. -----Depth of filter material____ ----------Total length........ ��E.�.�._ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line._._.._..__..._.. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------.----------.Dept h................................. Cesspool: Distance from nearest well.................Distance from foundation-------------------Lining material--------___._-_____---_-___-____._-_ ❑ Size: Diameter.--- -•-------------------------------Depth----------------------------------------------------Liquid Capacity_..........................gals. Privy: Distance from nearest well_________________________________________ _______Distance from nearest building------------------------------------------ 11 Distance to nearest lot line-----------_--------------------------•--------..................---------------•----------------------------------- ---------------------- Remodeling and/or repairing . 1 _______� Ji._____.. ______________________________ _____________________________b__________________________________ ------------------------------------------------- ---------------_____________________________________________________________________________________________________________________________--------------______•-__-.____.------.-•_-.----•_•------__________._____„______._ __ _________ ________________________________________________________________________________________________________________________________________________________________•______....____..______....____.____________...__.- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, and to” and regulations of the San Joaquin Local Health District. {Si �9ned)---- - ..--------------• • --- ----- •--•--•----...........•------------------------------------------------------------------------------------------------(Owner.and/*r=contractor] By:..................... - -------------------•------•---•------•------------------------------------------------------.-------------{rifle)-...-----------------------••--I------------ -------------- (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---------- BUILDING PERMIT ISSUED-------•-- -------------------------------------------------------------------------------------- D T ; Alterations and/or rocom"�endations:----'1�;A .�/-3---•------!1�E... . Q. --°-�... �_ .fry- -----�5-----t ----. . .fie--,r--- ------------------------- ----------....7-------............... ------------------------------------------------------------••-------•--------------------------------------------------------------------------•---------------------------------------••--•------------------------------- ----------------------------------------------------•-•-•-•-•------------------ --------------------------------------------------------------------------------------•-----------...------------------------------------- 7 FINAL INSPECTION BY:.!----- -- -- - -- ------- ----- --------- --- --- -SAN JOA JOA IN LOCA EALTH DISTRICT 130 South American Strout 300 West Oak Street 124 Sycamore Street 205 West 9th Strout Stockton,California Lodi,California Manteca,California Tracy,California E8 9 REVISED 8.99 $M 5-61 ATLAS _ `