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r V-3 FOR i _--�� ----------------- ------- ..------------------ APPLICATION FOR SANITATION PERMIT Permit No. ............_...._._.: (Complete in Du k This Permit Expires 1 Year From Date Issued Date Issued .--3.1 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 Ordinanc No. 549. JOB ADDRESS A D LOCATION_ . .. .. � • --•--------•••--•--••-••---•---•-•-••--••-• ---------------------------............. Owner's Name--___ ® : �;---- r I � � Phone Address----------- - ---- ----------- Contractor's Name------------- o-w - • - -- --------------------------------------------------------•--------.-----.-_-:.... Phone.................................... Installation will serve: Residence ®'@pa'rtment Hausa ❑ Commercial E] Trailer Court ❑ Motel ❑ OtHer'❑ i - ` bedrooms __0 Number of baths ---Z_ Lot size ..- " -,------------------------- Number of living units: __..____ Numbar of 1 . s i I Water Supply: Public system �Commumty'system ❑ Private ❑ Depth to Water Table I�(J ft. F Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan [] Previous Application Maden' (If yes,date-------------F------) No ® New Construction: Yes ❑ .No 2?—FHA/VA: Yes ❑ No E;— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within-200 feet.) S,Potic Tank: .Distance from nearest welL------ 1 --------- Distance from foundation------------- ...... _........ .._--.Material--_.------3 - ._____....:.......... &Aaf l-Tf No. of compartments-----------•--- ------•--Size--------------------------- ----Liquid depth-•-----------------• Capacity....................... Dis pogal Feld: Distance from nearest well-----------------Distance from foundation-_--_-__---..._.----Distance to nearest lot line................. tib !P Number of lines----------_----------------------Length of each line-•------------------------ .Width of trench '✓ Type of filter material-__--------------------Depth of filter material--------_-------.--------Total length__:= .�'---__...-_-_-_-:_-__-__-•••_•_- f ) f ff, Seepage Pit: Distance to nearest well----!�..---^-----Distance from foundation----3 _.__..Dis#ance to nearest lot ........ Number Number of pits----Y--------------Lining material.- ---Size: Diameter-.," l -"Depth----aa?` to Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-!--------------------------------------- # ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity (� 4 p tY--;:---••-------------------gals. Privy: Distance from nearest well-----__-----------------------------------------Distance from nearest building ' ❑ Distance to nearest lot line---------------- ' all� Remodeling and/or repairing ide`sci•ibe):---_- _-.-- Ir --------------•--.-.-------------•----- -----•------------••---------•--------------------•---- ----------••------•---.---•----••---------------- ------------- ----- I 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 andeguI tions of the San Joaquin Local Health District. � F (Signed)9 ------- -- r Contractor- ByL---------------_ - - - --- ................ ••••-----•----•------- Title--- {Plot plan, showing size of lot, location of system in relatio wells, buildings, etc., can be placed on reverse side]. - �- N ------------------------ FOR 2PPARTIMENT USE ONLY APPLICATION ACCEPTED BY--- --------------------------------�. DATE Y - =- ---------------------------------- "' REVIEWED BY -•---•--------------- ----------------- -----------------------------------------------------••--- DATE--------......... .. BUILDING PERMIT ISSUED---------------------------- - ------- DATE---•-----------•---------------------------------••---------- 1 i :.Alterations and/or recomm ndations:.-.-__.. ------------------ I. . -------------------------------------------- ------- ----------••-• ---•-. ........................................... --------------- --------- --------- --•-------------------------------------- bb r k. FINAL INSPECTION t- T BY..__a�, r_- ----- -------- Date-- SAN --. Z JOAQUIN LOCAL HEALTH 'DISTRICT 130 South American Strut 300 Wast Oak Serfef'�' '• } z ` � ' % t �_u 144 Sycamore Streeb� 205 West 9th Street Stockton,California Lodi,California Manteca,California % Tracy,California ES 9 REVISE" a-89 EM 9-61 ATLAS - -