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F R OFFICE S - ----------- APPLICATION FOR SANITATION PERMIT Permit No. (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 Ordi ance No. 549. JOB ADDRESS AND LOCATION --------�-o�.- -- -- ------------------------ ----------•---------- •-... Owner's Name.._�_,_a��----- Phone .... r Address-----------------------!/-----� ----------------------------------------- ---•-.------�...------------------------------------------•--------- �r c Steri Phone ................................... Contractor's Name---------�•------••--._...---•----•----------•---- ...--.-- •-----••----•--------------•------•-••-------.-.-•-------•-- Installation will serve: Residence ~Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ !; Number of living units: ------ t-- Number of bedrooms A___- Number of baths -__ .-- Lot size _.__....-.. ............................. Water Supply: Public system [Community system ❑ Private ❑ Depth To Water Table ____--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: {If yes, date________ _ _________J No New Construction: Yes �No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No se�tic tank or cesspool permitted if public sewer is available within 200 feet.) Sept' Ta Distance from nearest well__-___-______-.. Distance from foundation_________________ Material ---------------------------------------------- No. of compartments --------------------------Size-----•-------------------------- Liquid depth------- ------------------ Capacity -----•-----•-------- - -- Dispo 1 F d: Distance from nearest well_________________ Distance from foundation -------------------- Distance to nearest lot line ................. Number of lines ----------------------------------- Length of each line ------------------------------ Width of trench ----------------------------------- Type of filter material ------------------------- Depth of filter material --- --------- ----------- Total length ------------ ....----------- -•-----•-••---- __Distance from foundation-.�_-.D...._..__....Distance to nearest lot lin�_�--_---.- See it: Distance to nearest t well____"._�-_____._ �, Number of pits ------- -------------Lining material`.R4_G4- ----.Size: Diameter -3.4 - ......:Depth---- ��.___---------------- Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material ---------------------------- --_.�IS- ❑ Size: Diameter'--------------------------------------Depth----------------------------------------------- Liquid Capacity 9 Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ------------------------------------------ ------------------------------------------------------- ❑ Distance to nearest lot line ------------------------------------------------- 11 Remodeling and/or repairing (describe)- --------------------------------- •------•---------•---------•-----•----•----•---- .... I� �-------------------------------- •---•-•--•------------------•----------- ----- -------------------•----------------------------- -!---•-----••---------------------•------ --- - - .......'. --- ----- ----------------------•--------------••----•-- ------------ •---•------•------------------------------------------- w 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 re iatio s of th San Joaquin Local Health District. (Signed) (Owner and/or Contractor) By: ------------------- ---•------------ •--------------------------------(Title)----•--------------------------------- ---- -- -- (Plot plan, showing size of lot, to a ion of system in relation to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY ( BY -- - APPLICATION ACCEPTED ., DATE��= ! REVIEWED BY -------------------- •----------- - DATE ------------------------------------------------------------ BUILDING PERMIT ISSUED -----------�------------- ' ---- DATE------ - -------- - Alterations a d orC recomm ndations:_-___- ------ --------------- -- "------` . ---------- ! ---------------••------•-••---•-----------------------------•------------- ------------------------------------------------------------------------------------- I ---------------------- ----------------- ----------- ---- FINAL INSPECTION BY:.. --4 �-.. ----------- Date ..... :. I 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 Tracy, California I - ES 9 REVISED a-59 2M 5-62 ATLAS -