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FOR OFFICE USE: ------------------ ----- ------------ ------------- � --------------------------------------------------- ----- APPLICATION FOR SANITATION PERMIT Permit No. ....................... --------------------------------------------------------- (Complete in Duplicate) Z 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 an in all the work herein described. This application is made in compliance with County Ordinance No. 549. /f/5( ei • NESE—,t) . �I� JOB ADDRESS AND LOCATION...4:�_- -_2 - ,�` r .j_ -f'_:-- _-`V �-=--�' -'-t'-��-E-R'----. �IS1 �r Owner's Name---------------------------•--------------•• - -----------••-•--------------..�-----•--------------------•--•-----..._.. Phone .. .....lam Address-- ••_..... ........................ -----------------------•----------------•-•--------••---•-•-- ---------------------------- ---------------- --------------------------- ' Q � ----------------•--....Contractor's Name___ _ 2... --.....`/. fP Installation will serve: Residence [3'-'Apartment House ❑ Commercial ❑ Trailer Court ❑ M tel ❑ Other ❑ Number of living units: __1..... Number of bedrooms ---t--- Number of baths J... Lot size .......................... E Water Supply: Public system ❑ Community system ❑ Private El'-Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[9'Hardpan ❑ Previous Application Made: (If yes,date--------------------) No B�New Construction: Yes El"No ❑ FHA/VA: Yes ❑ No F3" 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-------------------..._..................... ..__. E� I No. of compartments--------------------------Size--------------------------------Liquid depth-----------------------..-Capacity....................... Disposal Field: Distance from nearest well________________Distance from foundation....................Distance to nearest lot line................. Number of lines---------------'------------------Length of each line------------------------------Width of trench--------------------.----------.-._ �G Type of filter material--------------------------Depth of filter material------------------7---Total length.......................................... "41 � : A v _ eepa a Pit: Distance to nearest well---.�.�--------.Distance from foundation........d_.___._.Distance to nearest lot h�a_____ _________ L C� ->�a Number of pits-------I-_-___-____--Lining material-_-____tea-f *_.Size: Diameter__,3:�__'____.___.Depth_ -....a�1. ,.. Cesspool: Distance from nearest well.................Distance from foundation-------------------- material..----------------------------------- Size: Diameter----------------- -----------De th---•--------------- --------Li Liquid Capacity ~ ❑ ---- --- i' ------------------------- q P tY-------•------------....----gals. � Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____-_--___-__------_---.--_-_----- ❑ Distance to nearest lot line-----------•--------------------------------------•--------------------------------------------------• •----------------------------------- Remodeling and/or repairing (describe):________ ._- ......- � �-' 1 _._.___, ____ ?-- .___ _____ _ �Q�z _ ,.�� C --••..............•-...__......---•--...-•--•---•--•-•---•-----••-•--•---•••-----------------•-•-•-•--••--------•----------•--------.....-----•-••---------------.....----•-----••------------•-------........_•---------•---- _ ------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------..-•-------------- I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tate laws, and rules and regulations of the San Joaquin Local Health District. [Si ned G �-c_-- _.- _-- _ .. ��'--- t: `-� {Owner and/or Contractor) g _ -- - - �.. ------ ---- ------- ._ Br--•-- tea+ ` '� .. ..... = = [rtlel ' � �� " (Plot plan, showing sizef lot, location of system in relation to wells, buildings, etc., can be placed on reverse si51'e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY,,0:;.4' --- ----___-----__-_-__-_ _______•___ -____ REVIEWEDBY------------------------------------------------------------------------------- ------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------- ---------•-------------------...................................... DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------ ---------------------------------------•-----------._...----------------------•-•------•------•-----•------•--•-----•----------------------- -----------------••-------------------------------•-------------------.---------------------------------------._-_--------•-••-----.---_----------•------__-.--------•-------•-------------------._-------------------•-••--- _------•--------------•----•--••--•---------••---------•---•-------------------------•---•-•--- ------------------------------------------------------------------------------------------------- ---------...... ------•------------•-•----•---------- .......---------------------------------------------------------------------------------------------------..__.-----._............---•------. -------•• •---....---------•--- FfNAL INSPECTION -------------------- Date--- ................................................ 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 ES 9 REVISED 8-89 PM 6-61 ATLAS