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FOR OFFICE/USE Permit APPLICATION FOR SANITATION PERMIT - ----- -------------------------------------- __-----. (Complete in Duplicate) Date issued ---- -- _--- --------------------- This Permit ExeireS t Year From Date Issued Application is hereby made to the San+Joaquin-Local Healfh 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-------------- ----------..... --------- Phone .. . Owners Name---------- ... = ' -_, �' ...._ •:�-�•�_� Address----_--••--------•-•- -- - ar one Contractors Name.........._ -, Installation will serve: Wesidence ❑" Apartment House ❑ Commercial E] Trailer Court [I Motel ❑ Other ❑ Number of living unfits; __ A_ Number of bedrooms _af--- Number of baths _. .... Lot size __-.----%'I_..._J�...r.Z_. `�-----•----• WetertSupply: Public system,�O�Community system=[❑ -Private ❑ Depth to Water Table _ . _ ft. Character of soil to a depth 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan F]of Previous Application Made: {1f yes date....................) No 0 New Construction: Yes [I -�o 0-- FHA/VA:Yes.❑ No 0� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SeptictTank: Distance from neares _ t well----------------- from foundation--------------------Material__.-.-..........._......_._............_:........ d depth......... . ..............capacity No. of compartments--------------------------Size-------------- Liqui -•--------------- - - ...•..-•-----.::.-----• ❑ 1 ! from foundation-----------...,.....Distance to nearest lot Nne.._...__.......-- Disposal Field: Distance from nearest well..................Distance ❑ Number of lines-------- Length of each line-------------------------- of trench-------_-----------....----------- Type of filter material_----------------------Depth of filter material-----------------------Total length.....-----------.••-----,---•--- I Seepage Pit: Distance to nearest well--- -e---Distance from foundation..__/..4�__-_:._.Distance to nearest lot line._ .._....._: Num4ber of pits..-------1.I----------Lining material----41 ----Size: Diameter------ ...... � --- ----------Depfi ----••---....---•-•------- ! Cesspool: Distance from ` ^ nearest well.................Distance from foundation--------------- material----------4-----.----•---- --els. \v� Size: Diameter--------- ----------- ------------- Depth-----------------------------------------------------Liquid Capacity-------------------•--------9 t Distfnearest building Privy: � Distance from nearest well------------- ----------- -•-------- .--.------Distance g--------•-------•-------••:--------•----- ❑ I' Distance to nearest lot line----------------------------- ------•-----------------------• I Remodeling and/or repairing (describe):1----- ---------------------••---------------- ------------...---- •------•--------.-- = --------------------- -----••-•--------------••-------•------------------ - -------------------------- ...............-------------------------- - ---------••------•---••---•-•-------••-•----•--------- -------•--4--•-----•• ----•----- { -----------------------------------------------•-------•-------•------•-----.......----••--------•---"--------------• --------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. i . ' - / - .- �- ----.�� (Owner and/or Contractor) --(Signed)--- 1Y" : .... ---•-- ---------_------- By- �K ... i (Plot plan, showing sire of lot, location of system in relation to wells, buildings, etc., can be placed an reverse side). FOR DE ARTMENT USE ONLY APPLICATION ACCEPTED B,'..- .. ------------•------------------•----- .. DATE U1•- , REVIEWED BY---------------1---------------------•--------1-- DATE----- ----------- �------------•------------ -------------------------...----------------•--- ,-•----------------------------------- BUILDING PERMIT ISSUED---------------------------------- ---------•---------------------- DATE--------------------------------------------- -----•--------- Alterations and/or recommendations:--------------------------- - ------------------------•---------•-------- ------------------•---•... ._� ------------------------------------------------------ ------------------------------------------------------------------------- ------------•---- -------- ------•----- Date.... FINAL` INSPECTION BY:.... ..... .... .. . .... .. -- - - -- •-- ---•-------- SAN JOAQUIN LOCAL HEALTH, DISTRICT 13-South American Street 300 Wesi Oak Street 114 Sycamore Street 205 West 41h Street Stockton,California t. Lodi,California Manteca,California Tracy,California ES 9 REVISED III 2M 3-61 ATLAS