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rvrt vrrrL,c va - ✓ ed ---fat'-----�' . .....,--------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .J... :-.-------------------------- (Complete in Duplicate) --------------------------- Date issued ...... -�-�---------- ---�--=----------• This Permit Expires 1 Year From Date Issued f 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 LOCAT N - C? � .-----•------ ........................ ' ------ -•---- Owner's Name...... n...........................------. •---•----...... ----- :_ =..__. Phone Address.................. .- ----�-- - - Contractor's Name - - ------------------------- - - : Phone .. _ ........ ...... Installation will serve: Residence [ifApartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units'. ..'Z__ Number of'bedrooms _ Number of baths Lot size .............................. -Water Supply: Public system (Community system ❑ Private ❑ Depth to Water Table _Ia ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑ 1 Previous Application Made: (if yes,date--------------------) No [T3 New Construction: Yes ❑ No FHA/VA: Yes ❑ No 2�—. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within-200 feet.) SF tic Tanks '.Distance from nearest well_________________Distance from foundation___..__=----------.Material................................................. No. of compartment's------------------- -----Size_._......------ ----•--.......Liquid depth--------------------------Capacity------------...•-•----- Disposal Field: Distance from nearest well_____-:.---.-Distance fr`ofoundation______,�, .J---Distance to nearest lot Number of lines........ _ line ' n yp 1.---..- den th�of each -• -- -- -� .:...---Width of trench.--- _•y---------------------- �i ---- Type of filter material/_A/Is�fl _pepth of filter matenal..__1�_.____._._Total length----------- ______......________•__-. \n Seepage Pit: Distance to nearest well---- ---------Distance from foundation-.-/1-_.___.:=.Distance to nearest lot line-'_--__--- ❑/" Number of pits..../---------------Lining matarial__ Q ----Size: Diameter__. _---___.-_-__.__- :Cesspool: Distance from nearest well_________________Distance from foundation-----_------------Lining material------------------------------------- 0 Size: : Diameter----------------------------•---------De th-------- .-----•--•------------ -------- Depth Liquid Capacity_- ------------ .....gals. <: Privy: Distance from nearest well----------------------------------------- -------Distance from nearest building-_-----------------------.--------- ❑ Distance to nearest lot line---------------------!�-:_____ ----------- - �•, _ _ _ _ ---------------------- Remodeling and/or repairing (describe) -------- ...� ---•---•---•-----•-- ----•------•------•-------- � ' ' --•-----------•------•---•--------•-•------------------- ------------- ----------------•--------•-----------•--------. •---• -.....--- ---•----•---•--- ---••------------•-----------....---- -------------------------------- ----- -------------------•--------••-----•------------•-----------L------------------••---------------•-------------------•---•-----------•-------•---•-----------•--•-------------------- 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 d regulations of the San Joaquin Local Health District. ( �gSt ned )------------------•-•------------ •-- -- -------- ---------------------i------------------- ---- ------------•----•• ---•--•-------------------(Owner and/or Contractor). By--•-•--- ------------------{T+le) 7r --------....... - - .... (Plot plan, showing size of lot, location of system in r ion;to wells, buildings, eft., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----V,_ DATE REVIEWEDBY-------------------------- ----------- ---------------------------------------------------... ----------- DATE ----------- BUILDING PERMIT ISSUED -----•------------------------••-•-------------- DATE ........... •=-------- q Alterations and/or recommendations:______ _�______----- -------______-.-___ --� --- h- -- - --- --------:ems...------------I -------------------•--------------------f--------------------------------------- ---------------- ------------------------------------ -------------------•------------------..-..------. •--- ----------------------•------------------------------------ -------------------------------- -----------------------------------•------------------•------------ FINAL INSPECTION BY------- Date� ---- l `� I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American street 300 West Oak Street, 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California ' �' ` Mantica,California Tracy,California ES 9 REVISED 6.59 2M 5-6I ATLAS r y � 1