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FOR OFFICE~.US : - --------------------------- - _ ....._-----____________ APPLICATION FOR SANITATION PERMIT Permit No. .., ._..-r.� ... `�� - 3�� D-3------------------ (Complete in Duplicate) -------------------------------------------------------._ This Permit Expires 1 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. p JOB ADDRESS AND LOCATION........ _ Owner's Name---•----- -�-��N---•---------- -ft"SS---------- Phone - Address-----------_-•--- Contractor's Name----- Installation will serve: Residence ❑ Apartment House ['Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units- ___��Number of bedrooms --7�Number of baths Lot size ___- -------- --------- _--.___._______ Water Supply: Public system [Community system ❑ Private ❑ Depth To Water Table b_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,d❑te--------------------) No Er New Construction: Yes ❑ No [EI' FHA/VA: Yes ❑ 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 depth--------------------------Capacity-•-•----•- •---------- Disposal Fiel : Distance from nearest well---A9 _Distance from foundation___1_p.........-Distance to nearest lot line...__.....__. to CNumber of lines_-........ -----------------------Length of each line---------A-_,'_`..........Width of trench___.________,�4_."�_.___.... Type of filter material._._�?Pc -------Depth of filter material.__-:.. .._Total length__________________Z: Seepage Pit:' Distance to nearest well---&Q_N6----Distance from foundation----- '....Distance to nearest lot l•i-n.e._ .-� _�._- Number of pits material___-- K__--.Size: Diameter--- Depth---------- - Cesspool: Distance from nearest well-----------------Distance from foundation__----------------- Lining material------------------------------------- M Size: Diameter-------- --------------------- -------Depth---------------------------•------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------------- -------Distance from nearest building---------------------------------------... ❑ Distance to nearest lot line------------------------,----- ------ -------- ----------------•- _---_----------------------------------------------------------------- Remodeling and/or repairing (describe):--------� C__--_ .... .... ........ . .. . .....-1 -rcr—------------------------------------------ ----------- •------•--------------•-----------------•-•---------------- -----••-------------•------------------------------•------------------- ---------------------•---------------------••---------------•-•----••------------------ 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)-----------'25-_all,----- ... c /e( z q- -------- �' -�-------------------------(Owner and/ r Contractor) By:.......... z -----� " (Title) 6� (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY � ® r- - APPLICATION ACCEPTED BY____ �"Y`� _________________ DATE...... '_.._�-_-._---.--------.- REVIEWEDBY------------------------------------------------------------------------------------ ---------------•----------------------- DATE-----------------------------------.................. BUILDINGPERMIT ISSUED-------------------------------- ------------------r--------------------------------------------->._ DATE.-------------------------•---�----------•--•----------- Alteratio�s ani/or recommend'ations:_____. c �Y, t_= .____ - __. sr`�.•.•.. .....__- ------------------------------------------ ---eic----------------------- ------------------------ ----------------------------------------•-- -- -------------------------------------------------------------------------------------------------------------- -------------------------------- ----------------------------------------- FINAL INSPECTION BY:----411-- -� --• --.�.1�� ------ -- Date---'=��------------------ - - ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Swat 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 zM S-62 ATLAS