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/(FrR OFFICE USE:-- ------------------------------- - J `� 7 .................___._.._-..---__---.----- .---- APPLICATION FOR SANITATION PERMIT Permit No. ........ZQ.l....f --------------------------------------------------- - (Complete in Duplicate) V -------------------------------------------------- -- - - This Permit Expires 1 Year From Date Issued I!_ Date issued •� �?___.�. 7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wo k herein descrbed. This application is made in compliance with County Ordinance No. 549.E 4- , � ,� ,�/ JOB ADDRESS AND LOCATION --- - -- ...... = Owner's Name------ ------------ - ------- ------- Phone_-�.3-•-% --------- ----- Address--•----- Contractor's Name...............-...... ----•-•-------------------------••------ Phone................................... Installation will serve: Residence [�. artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms _Z- 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_..................) No ❑ New Construction: Yes ❑ No ❑ FHANA: Yes ❑ No ❑ W TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep Ec Tank: Distance from nearest well-----_��_____6__Distance from foundation_--_s J� ----Mater�l----__--_ No. of compartments------------a�---.s Size----.-.-----� ---------------Liquid depth____-----------------Capacity--//0--- --- �" Disp al Field: Distance from nearest well�__,574..._Distance from foundation----1.J-------Distance to nearest lot line----------------- Number of lines------------r9_-----------___. --Length of each line-_----_ f �i.l�--- ��---.Width of trench----_--r�----'----------------------- Type of filter materia Depth of filter material----,��__--__._.Total length._._ _Af_ --_------------------ Seepage Pit: Distance to nearest w ------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------------------------------------- El Size: Diameter---------------------------------.....Dept.h----------------------------------------------------Liquid Capacity---------------------------- r Privy: Distance from nearest well----------------------------------------- ------Distance from nearest building--------_-..--_--------------.---------- C5 ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------•--------------_----------------------- Remodeling and/or repairing {describe): ----------------------•....----•--•-----_--------------------_------------ F ----------------------------------------------------------------------------------------------------------------•---_-._•-.-._.____-..--_---.-------_-_-_-_--.----__---...__.._____-----__.----._-___-----_---_._.__._._--._-_ 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)-------------------- •-•--•-•------••- ------------- --------------------------------------------------------------------------------------------------------{Owner and/or Contractor) By:------------------ ------------------------(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 APPLICATION ACCEPTED BY------ - 1 ---------- ---------------•------------------ --- DATE...........�� 1� � ��----------- REVIEWED BY------------------------------------------- ------------------------------................. DATE-----------. ---••--- ---------•---------••------------ --------------------- -------- -- ------------•------ ... BUILDING PERMIT ISSUED-----•-------------------------- ------------------------------------..__...--------------..__._... DATE------------.----------------------6------------------------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------••-•--•--•-•------•-------•-•-----------..-.---- -------------------------------•...--•--_-_--•------------._....-.----------------------------------------•-------------------------------•-•----------•------------....--••_•-•.........---------------•---------------•--_- ------------------------------------------------- --------...------------ --------------•-•--------------------------------------------- ---------------------------------------------------.................---•-•---------- ------------------------•--------- -- •-------•----------------• ------ ----------•--•-- )lt 1410 t7/ FINAL INSPECTION BY--- -------------- s -------------- Date-------- - ---------1/_6_6__-_6_6-------------------------------- SAN JOAQUIN 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 8.59 2M 5-62 ATLAS '