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FOR OFFICE USE <br /> ------ - -- -- <br /> ...3_6-------III------ Permit No. <br /> APPLICATION FOR SANITATION PERMIT <br /> -ate) <br /> ----------­_­------------ <br /> ------------------ <br /> -----------------I----------I-------- <br /> (Complete in Duplic- d ---- <br /> 0------ This Permit Expires 1 Year From Date Issued <br /> Date Issue <br /> - ------------------ - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. <br /> This application is made incompliance with County Ordinance No. 549. 70,_ <br /> JOB ADDRESS AND ATIO 7.2 -- -------- ------ ---------- <br /> - ------- -------- <br /> - ---------- ------------ -------------------- --------------- <br /> Owner's Name-------- --- ------- ------- <br /> Address----•----..... ... .... ......... ------ <br /> ---- ---------------------------­- ---------------- Phone__-X_,m-,-�.r-------------- <br /> Confrador's 1,Namay ---- -- --------- ----- -- --------------------------- <br /> Residence Apartment House [] Commercial E] Trailer Court 0 Motel E] Other El <br /> Installation will serve: <br /> Number of living units: Number of bedrooms -.7--- Number of baths --rT Lot size --- --------------------- <br /> Water Supply: Public sysm [I Community system C] Private a Depth to Water Tablets ft. <br /> Character of roil to a depth of 3 feet: Sand L] Gravel [] Sandy Loam [] Clay Loam [3 Clay [:] Adobe, Hardpan 0 <br /> II! ' <br /> Previous Application Mad.e: {if yes,date_-_----------------) No Now Construction Yes. ( No [I PHA/VA: Yes E] No El <br /> ij. <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-----------------Distance from foundation------------------Material-_____.-____________________.....__-____---._.__. k <br /> ❑ <br /> aterial------------------------------------------------ <br /> El No' 0 compartments.-------------------------Size-------------------------------Liquid depth----------_--------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well-------------------Distance from foundation--------------------Distance to nearest lot line.._..__..___..... <br /> 1! <br /> Numbe' r of lines-----------------------------------Length of each line-------.--------:-------------Width of french------------------------------------ <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length________________-:_.--________________..__ <br /> Seepage Pit: Disfaq e to nearest %1011.-/.C.<S�ista nce from foundation---/&OADistance to nearest lot line__. v <br /> ,[�/ Numb <br /> ine--- --- <br /> %4 r of pits-6--------------------Lining material----------------------Size: Diameter----------------- Depth----._.._.._-----.---------____-. <br /> f <br /> Cesspool: <br /> epth------------------------- <br /> Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material________._-.___________-_.--_-_--_-_. <br /> EJ <br /> aterial------------------- ------------------ <br /> EJ Size: Diameter------------------------------_------Depth---------------------------------------------------- Liquid Capacity--------_------------------gals. <br /> Privy- Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> F1 Dista:'11 I <br /> nce to nearest lot line------------------------------------------------- ------------------------------------------------------------------------- --------__-------- <br /> ----------------------------------------------------- --------------------------------- <br /> 11ing -------- <br /> Remodeling and/or repa, <br /> ------------------------------------------j--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------- --------------------------------------------------!-----------------------------------------------------------------------------------------*---------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------•-----•• -------------------------------------------------------------- <br /> I hereby certify thaf!i have prepared this application-and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Sign edy—k-,�--- `4--------------------------------- ---------------------- wn and/or Contractor) <br /> By:-------------- ----------------------------- ----------------- --------------------------------------------(Title)--------------------------------------------- ------------- <br /> (Plot plan, showing size ot lot, location of system in relation to wells, buildings, eft., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -------------------- ------------------------------------------------- DATE------I-------------- --------- <br /> ................. <br /> REVIEWEDBY-----------------I--------------------------------------- ------I----------------------------------------------------------- DATE.-------- ------------------------------------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------___­--------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or-recorri'm 11 endafions:----------- ----------:---------------------------------------------------------------I——------------I-----------------------I--------­­­­--------- <br /> ------ ----------------- ------------------1 9 11-1--------------------I-I- <br /> --------------------------------------------------------------------------------------------------------------------*-------------------------------------- <br /> -------------------------------------------1-------------------------------------------------------------------------------------­­---------------------------------------------------------------------------------------- <br /> :Ili <br /> ----------------------------- ------------------------------------------------------------------------------------------I......... -------------------------------------------------------- -------------------------------- <br /> ---------------------------------------------------------- --------------- ----------------------------------------------------------------------------------------------------------------­------------------------------- <br /> --------------------------------- <br /> FINAL INSPECTION ----------------------------- Dat <br /> ----- ------ <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 /> E6-9 REVISED 0-59 F.P40.21A 6,60 <br />