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FOROFFICE USE. -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------- --------------------- (Complete in Duplicate) ---------------------------- ------------- ... This Permit Expires I Year From Date Issued 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. JOB ADDRESS AND LOCA 0 ........ --------------------------------------------..................................... Owner's Name___.__ --- ------------------------- -------------- -------------------------------------- Phone------................... ---- ----- -- ------ ---------- Address.........A - - --- -------- ---------------------------------------------------------------------........................................................ Contractor's Name----- ---- ----------- ----- ------------------------------------- ----------------_-- -------------------•......... Phone................................ Installation will serve: Residence Ur"Apartment House 0 Commercial [:] Trailer Court E] Motel C] Other [] Number of living units: Number of bedrooms Number of baths Lot size Water Supply: Public system b_,_�Community system 0 Private E] Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand [] Gravel [I Sandy Loam E] Clay Loam [] Clay [-] Adobe fl' Hardpan C1 Previous Application Made: (If yes,dote--------------------) No ET' New Construction: Yes-E?"No C] FHANA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S,-pt'c T nk: Distance from nearest I well,-Aarvd-----Distance from foundation- Y__'1.___.MateriaI 4.!11_� .........!"'` 7....... ....I........ No. of compartments---._:2---------------Size---- ---------Liquid depth--------f_'_---------Capacity Disposal ield: Distance from nearest ..-Distance from foundation)P_7----------Distance to nearest lot line.'�> --------Iline-.--------40-------••----.Width - ---------------- Number of lines---•--------- Length of each of trench..._r ................... Type of filter -- -----_Depth of filter material----/-r- - .41 . --------Total length--------� AP----- -----, -- f Seepage Pit: Distance to nearest yell_-*---- - ----Distance frgm foundation---ZQ...........Distance to nearest lot line Number of pits____. 4 ----- -----------Lining material-----OW- _CKSize: Diameter__...17...........Depf h-------------- ...... Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.--_._--..-_-_____.__....::__...._ ❑ Size: aterial---,-------_----------- Size: Diameter -----------Depth----------------------------------------------------Liquid Capacity......................... 9 als. Privy: Distance from nearest well______________.__ ____._______-_-------------Distance from nearest building------------------------------------------- El Distance to nearest lot line... Remodeling and/or repairing (describe):-------------------- --------------- -------------- -----------------------------------------------------------_......................................... ----------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------- ---------- -------- ----------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------1.--------------------------------------------------------------------------------------------------- I hereby certify that I have prepared pthislic ion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulati o he Sa Joaquin Local Health District. (Signed)--------------------------- ------ ------- ---- --------------- -_ - _ - - ------------ --------- ----------------------------------------------------_-------------(Owner and/or Contractor) By:-------------------------------------- ;, .............. ------- ---------------------------------------------------(Title)------------------------------------------------------ --------- I ti" I I' (Plot plan, showing size of lot, location of s em in rel tion to wells, buildings, etc., can be placed on reverse side). FOR WVENT USE ONLY APPLICATION ACCEPTED BY <7 0/ IM -- ------------------- -- ------- -------------------•---------------------.._ DA REVIEWED BY TE------- .... .............�rj... --- ------------------------------------------------*----------------------- DATE BUILDING PERMIT ISSUED----_-----_------------------------------------------------------ ----------------------------- DATE.---- Alterations and/or recommendatigns:------------------------- 7 ---------------------- . . .. . ........ x -----•----r --------- ---_------------------- V, - ----------------------------------------------- ---------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- ------------------ ---------------------------------- --------------------- ------------------------ ----------------- ---------------------------------------- FINAL INSPECTION BY:------ . D ..... ---------------- ate........ 2 ................ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California TraCYr California EG 9 REVISED a-59 RM 5-61 ATLAS q I