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FORF,1E/U3- 3 .._eI�(.� _G_. ___---_ APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------ ------------------------ (Complete in Duplicate) ...--- This Permit Expires I 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. S49. JOB ADDRESS AN CATION--•-••. ?? 7 -----------------------------------------/ --•--•-----------•--------- •- Phone.Owner's Name- - Address. ---•--. ••--•----------••----------------••-----......................................................... Contractor's Name................... .......... ------- -----------------• -------•-•-----••--•--- Phone.................................. Installation will serve: Residence g partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/-__ Number of bedrooms _,/-_' Number of baths __/. Lot size --/& ------- A-014-01 ...... ....................... Water Supply: Public system E] Community system F] Private Depth To Water Table '41e ft " Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: llf yes,date--------------------1 No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ -V E OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i T = Distance from nearest well________________Distance from foundation....................Material---______-_____._____________---_______-_---_---. No. of compartments--------------------------Size--------------------------------Liquid depth---------------- ---------Capacity....................... �) 49;d: 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----._.._................................. Seeps a Pit: Distance to nearest well@®_____-_____Distant r)m f ndation_._ --- •_-.Distanc%to nearest lot ling........... Number of pits_________________Lining material1-0-04t__ -"size: Diameter__. 3--____.___.Depth��_______---._________ Cesspool: Distance from nearest well_________________Distanfrom foundation--------------------Lining material____.___-_--___________________-_-_-_ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity`.........-_._-._-.._.._..gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-----------------------.-_-___-_---____-_. ❑ Distance to nearest lot line--------------------------------------------- - ----------------------- ---------- ------••-------•-•------------------••------------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------•------••-----••----------------•---•-----------------------------•--------•••------------•-----------•-------------•------------------------------ ------------------------------------------------------------•--------------••---------------------------------------------------------------•-------------------------------------•------•----------------------------------- hereby cert' hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanc , Sta law , and rules nd regulatio of the San Joaquin Local Health District. I (Signed) +..__ i .- ---------------- net end/or Contractor] By:...----------------------- ---- ----------{Title} --�-• ----------••---- ------ ------- (Plot plan, showing size of lot, location of system in relation to we buildings, etc., can be placed n reverse side]. FOR DEPART NT USE ONLY l APPLICATION ACCEPTED BY----- ------__ _ ______- DATE--.-_-3`__-----__--- REVIEWEDBY------------------------------------------ - -------------------------------- -----•------------------•----•-------•------• DATE-------.-_---------•--•----------------------------------- BUILDING PERMIT ISSUED---•------_--- - -- ---- - ATE. ----------- Alterations and/or recommend'ations:__ � _ _ �! :.._ rr .. �__________________________ I ..........•-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------..._...........---....------.... ---------- -- -------------------------------------•----•--•-------•-•------------------------------------------ ---------------------------------------------------------_-••----.--..--------------------------------------- -------------------•---•--••----- ----------------------------------- ------•-•--•---•-------------------------------- ------'------------------ ----- ----- --------------------- ---------- -------------------•--------------------------------------------------- ------------------------------- � � I FINAL INSPECTION Y:.- ` t % -i;� :f..._ Date. '�'� ------ / SAN J,OAQUIN LOCAL HEALTH DISTRICT ` 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 2M 5.62 ATLAS