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FOR OFFI E USE; (,� 7 r '^ ��-�v-----ILS_. -- ----- - -- � Permit No. .__;l....7..__7:.'2'-S APPLICATION FOR SANITATION PERMIT ------------•---------------------------------- (Complete in Duplicate) Date Issued _�/� _____-_..._._______.__.___ This/permit Expires 1 Year From 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. 5 49. JOB ADDRESS AND OC TION - " ;, -�f- Owner's Name.._ --------------------------------------------- ,72Phon 1�' �_.. ._. _ ••------•---•--------•-• ------------------ 5 __ `--sem_ � � -----•............................................ Adclress.,�:,�_-r:2_ ----•---•-•-------• Contractor's Name.................... - ---- .. -<•! - ----------........;...................... Phone..___---••------------------- --�. Installation will serve: Residence [� A rtment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ T. r 4ot size � Number of living units: _�..-. Number of bedrooms __1___ Number of baths = Water Supply: Public system Community system ❑ Private ❑: Depth to Water•Table _ V! ft. Character of soil to a depth of 3 feet: Sand d Gravel C3 SandyLoam ❑ Clay Lorr► Clay Q Adobe[3 Hardpan C] l Previous Application Made: (if yes,dote--------------------) No`❑ New Construction: Y": E] No ❑ . FHA/VA: Yes�D No ❑ ► TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet] Septic Tank: Distance from nearest well_________________Distance from ❑ foundation--------- ---------Material---.-_-________.___--------_---___--- -------- .- No. of compartments_._..-•----__ -----------Size------------- • -------•-------Liquid de h--------------------------Ca acity------...__- . 'Distance from foundation____-_ ._ .__.Distance o nearest lot line.................. Disposal Field: Distance from nearest well-__._` r ' ,zF Number of lines----------_-•---�ry----- ------Length of each line------------ ........Width of trench---------- _...--••---_..__ Depth of filter material_..--- - -r�----Total length--__-_-----r -----------------•-••- Type of filter material__._.1l� ---._ .` Seepage Pit: Distance to nearest well----------------------Distance from foundation---------f.........Distance to nearest lot lir%e______---..._____ v l ❑ Number of pits----------------------Lining material--------------••-----..Size: Diameter-----------------------Depth--------------------------------- " l Cesspool: Distance from nearest well_________________Distance from foundation.-..__-. ____..__.Lining material------------------------------------- ID Size: Diameter----------------------------------- Depth------------------------------------------ Liquid Capacity...- gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line--------------------------------------•--------••---------------- -----• ---••-----------------•----- --•--- t �. �J f Remodeling and/or repairing (describe): •------ — .fe'r .+... ------------- ----------------------••----- •-------------------------------•---------•••------------------------------•-•------•--------------••----------------------•.------••----------- --------- 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 and regulations of the San Joaquin Local Health District. (Signed)...--- Owner nd/or Contractor) ------ ----- �� Title------------•--•-•-----•-------------------- - ---------------- ----------------- (Plot plan, showing since of� tr , location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------•--------------------------------------------- r _ � DATE------- REVIEWED BY. ----- ---------------- DATE ------------------------------ ---•- - BUILDINGPERMIT ISSUED.........--------------------------------------------------------..-----_.... --------------------- DATE--------------------••--------------------------•------------ Alterations and/or recommendations:-------------------- ----------------------------------...--•------•-----•-•-----------•----•-•-___--------------------- ------•------••---- ..................•--I.- --------------................................... FINAL INSPECTION BY:__ .. ��•: '.�_k_._S_-.--_---- --------• Date_.._ . ._Z------•--------� ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 205 West 9th Strut Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6.59 ZM 5-6t ATLAS