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FOR OFF E SE: � ................�.M- .___.``:.____-_..____-_._- APPLICATION FOR SANITATION PERMIT Permit No. ....... ....l.... � - (Complete in Duplicate){ P P� ) 7 -.---.-.--- This Permit Expires 1 Year From Date Issued Date Issued ---_,.__�_-6__ " Application is hereby made to the Sen 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 LO ION ___ _- W ---------------------------------------•---•-•--•----------------------------••---•--•-------------------------..-----•----•---- t Owner's Name-------//.L��.-----'�?.✓ -f-•-••--------------------------------------------------------- ----------------- �---- Phone..---------------------------------- Address -- •. Contractor's Name------ one i ---------•----•-------------------••------•--------------- ------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-.___ Number of bedrooms __I-- Number of baths ____�__ Lot size -----4.g__/j.9......................._-_._...__ ' k Water Supply: Public system [Community system ❑ Private ❑ Depth To Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe(3'Hardpan ❑ ,. Previous Application Made: (If yes,date--------------------) No [ New Construction: Yes-tr*'�No ❑ FHA/VA: Yes ❑ No R� TYPE OF INSTALLATION AND SPECIFICATIONS: (Na septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi ank. Distance from nearest well___________ Distance from foundation______----_-.__._.Material________________________________________________. !' �� No. of compartments------ -•-----------------Size------------------------------..Li..Liquid de th---A---------------- ----Ca Capacity .. q P. P tY I Dispo Field Distance from nearest well_________________Distance from foundation------------........Distance to nearest lot line................. Number of lines-- :--------------------------------Length of each line------------------------------Width of french------------------------------------ Type of filter material.......•-----------------Depth of.filter material----..----.----_-------Total length----------------------------.------------. See a Pit: Distance to Bares well-r '!�_-_Dist ,—rom undation-?'� _..._._Jistapce to nearest lot line__Sr_... �O Number of pits_._______________Lining materiallLClG_ Size: Diameter___.__3_.-----------Depth_-_..-��5.-._ Y . Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.____-___________.________..__.____ ❑ 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):--------- ---------------------------------------------------------------•-•--•----------.-..-.._...----------..---- ---------------_------------------------------ )------------------•-------------------•---•- I - ------------------•----•---------------------------------------•-------------------------------------------•--•-•------------------- ----•------••------•.-_-....--...-------------------•------------- 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 and regulations of the San Joaquin Local Health District. (Signed) r - ----------- ---•----------------------------------- ----(Owner and/or Contractor) B ' ....(Title)---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I , E FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- r! -r x ------------------------•--•-----------------.---------- DAT'E----- 7- l " �� • r REVIEWED BY-----------_---- -------------------- --- ------------- ------ DATE--------- BUILDINGPERMIT ISSUED---------------------------------- ---------------------------—--------------------•-- •------------ DATE-------------------------------- .--.----- •--••----- Alterations and/or r ommendations: r -------------- . ------------ ... •--...-•---•----•---...----••-•-------------------• + - - ... ---- -------------------------------------- --------------------- -•------------------------------- -------------------- ----------------------------------_ ---------------------------------------------------------------------------------------------------------------------------------------------------...------- f � FINAL INSPECTION BY:..- J.r ---------- Date---- ` I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wed Oak Street 134 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California d E5 9 REVISED 8.59 2M 5.62 ATLAS '