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FOR OFFICE USE: <br />--------------------------------------------------------- <br />----------------------- <br /> ----------- <br /> s. ` <br />.......................... ......__.-- - <br /> .-- APPLICATION FOR`;jANITATION PERMIT Permit No. .. ._. . <br /> 7- ---- --- (Complete in Duplicate) <br /> / Date Issued /n <br /> Application <br />----------------------- - -------------- -------------- This Permit Expires 1 Year From Date Issued 4/� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. S49. <br /> JOB ADDRESS AND LgCATIIO/N.._ _- <br /> --------- - -4-----•--;? ------------------------------------------------- <br /> Owner's Name.........l�'� 1.__. .. ------------ Phone.................................... <br /> Address-------------------ems <br /> Contractor's Name- '--'- ----------------------•---------------------------------•-------------------------.--------------------------------- Phone................................ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer_Gem*,M Motel ❑ Other ❑ <br /> Number of living units: ---!,. Number of bedrooms Number of baths .1.. Lot size �__41-2-.S- <br /> Water Supply: Public system ❑ Community system ❑ Private M Depth To Water Table left. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam,® Clay ❑ Adobe❑ Hardpan.ED <br /> Previous Application Made: IIf yes,date------------ ----} Noz New.Construction: Yes V No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> '(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-,z a--_---.-Dista c fro foundation.-/� _----_--.Material.............. ............................... <br /> No. of compartments-__.,A------------------size _- t-_S:_ Liquid depth--...f,�_�..--------------- _-Capacity_ _I . <br /> Disposal Field: Distance from nearest well 47---------Distance from foundation-Zr F ..........Distance to nearest lot line.) .......... <br /> Number of lines---------/_.--••------------------Length of-each'line-----1.0...................Width of trench-----�:`{- ------ - <br /> Type of filter material -----Depth of filter material-----L_Q------------Total length---1�............................. <br /> Seepage Pit: Distance to nearest well---/#7?-----------Distance from foundation-./o'_._._..___.Distance to nearest lot line-_-5---__----- <br /> [� Number of pits---.f----------------Lining materiaL/.t�----------Size: Diameter---. �-`_.____Depth----e2c_ia--------.._._____ <br /> Cesspool: Distance from nearest well_---------------Distance from foundation-------------------.Lining material---.--._---__---___--_--__-----.-_-_-� <br /> ❑ Size: Diameter--------------------------- ----------Depth----•----------------------•------------------------Liquid Capacity----------------------------gaIs. <br /> Privy: Distance from nearest well--_-------------------------------------------_Distance from nearest building------------._-----_----__--------__---_-. <br /> ❑ Distance to nearest lot line--- ------------------------------------------ -- <br /> Remodeling and/or repairing (describe):-------------------------------------- ---------------------------------•--------•-------------- ------------------••----•-----••------------------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------- <br /> -----------------------------------•-• ------------------------------------------------------------------------------------------------------------------------•----------.....- -------- --- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State?llawss, and rules and regulatio s of the San Joaquin Local Health District. <br /> (Signed)--.- ` ------ ----------- ----------- ------------------------------------------(Owner and/or Contractor) <br /> By----------------------•-------------------------------------------------------- -----------------------------•--------•-------- -(Title)------------------------------� --------- ------...__-..------- <br /> (Plot plan, showing size Of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � ------ -- 1---------------- --------•----------------------------- DATE-..!Y -43 <br /> REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------------- <br /> BUILDINGPERMIT ISSUED--------------- ------------------------------------------------------------------------•----------- DATE----------------------------------- <br /> Alterations and/or recommendations:------------------------------------------ -- - ---------•-•--------------•--•--•-••-•----------------•-•--------- <br /> -•------------•------------------------------------------------------------------------------------ ---- ------------------•-------••--•---••---------------------------------------------------------- ------------ <br /> -------------------------------------------------------------------- <br /> , <br /> FINAL INSPECTION BY:- -- - -- -----•- ------ Date- 4-- "-/------------------- ---•------------------. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 8.59 2M 5-62 ATLAS '�4 <br />