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FOR-OFFICE USE: 4. -------•------ ----- - ____ APPLICATION FOR SANITATION PERMIT Permit No. _ ..._......-S - --------------------- ------ (Complete in Duplicate) l Date issued --_._..--___-_----.- ------- ___________________ This Permit Expires I 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 a plication is made in compliance with County Ordinance No. 549. ,ems. � JOB ADDRESS AN OCATION ,-/--�- -------- .._. 'f k Owner's Name •. ------ --------- •- ---------------- ------ ---------------- - --------•------------------------- --•--- Phone---------------.........--•- ---•-• Address----------- . ••• --• -------------------------- - - --- -- - - •----------------------•-•-•-•--•-------------•-------•---------- Contractor's Name------ - ---------- ---------------------------------------------------------------------------------------------------------------•----- Phone................................... Installation will serve: Residen e tZ Apartment House ❑ Commercial [I Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.. Number of bedrooms __1---- Number of baths ---)... Lot size _ Water Supply: Public system ❑ Community system E] Private .2- Depth TO Water Table _12.ft. Character of soil to a depth of 3 feet: Sand 2(, Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: [If yes,date--------------------I N0-1b New Construction: Yesj:�—No ❑ FHA/VA: Yes ❑ NoQ 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-1-75-/Distaoa from foundation------�0-------Ma al ...Liquid depth of compartments_+�_--_---_____-___Size-- X -:-.----_C Disposal Field: Distance from nearest well-1_7 ....._Distance from foundation...-L_�.#_........Distance to nearest loiity�l''ine Number of lines---,,__________________________Length of each line__?____--- Width of _-_______--.-- Type of filter materialZ_'j� r____Depth of filter material---- _-------------- _Total length _D----....__.. Seepage Pit: Distance to nearest well __________---___-:_Distance from foundation.........-----------Distance to nearest lot line----------------- , = ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----•---------- ........Depth----------------....-________---- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.________--____________._..._..._-_ 1� ❑ Size: Diameter--------------------------------------Depth------------- -----------------------------------.,Liquid Capacity---------------------------- gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--_________________------.._________-_---. f ❑ Distance to nearest lot line----------------------------------------------- ------------------------------------------------------------------------------------•-------- Remo tiling and/or repairing (describe):_-- ------•-----------------------------------------------------P-------LAts'application -------------------------- --------------•---------------------------------.....------••------------------------------------._.. I herebycertifythat I have prepared d that the work will be done in accordance with San Joaquin County ordinances, State ws, and rule and r of the S n Joaquin,Local Health District. (Signed). ��""---./__[------ ----- ------------------------------------------•-------------------------------------------------------------(Owner and/or Contractorl B -- --------- ----- ----------------'---(Title)--------------------------------------------.------------------- (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 APPLICATIONACCEPTED BY----------------------------- - ---------------------------------•------------------------------- DATE-----------------------------------------------------------. 1 REVIEWED BY DATE...... ....... . ... / 14,E BUILDING PERMIT ISSUED--...-.---------------------------------- _------ DATE---� :'2' ..-v--O--3:--------------- Alterations and/or recommend'ations---------------------------- ----- -------- ------------------------------------------- ------------- .......................... -••----------------•-------- -------- -------------•---------------------------------••-•------------• ----.....------------•-----------------------•-------------=------•--- FINAL INSPECTION BY:.. .. . ........... = -------- Date---------- • ''--z- ------------------------------ 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 E5 9 REVISED B-59 ZM 5.62 ATLAS