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I FOROFF <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> --------- ----------------------------------------------- (Complete in Duplicate) <br /> ----------------------- ---------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <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. 549. <br /> JOB ADDRESS AND LOCATION ..3.. -------5,-----&A� <br /> ...................... <br /> ..... ........................... <br /> Owner's Name- ---• --------------------------------------------- ------- Phone_,Y-49----2-2_49.24P <br /> A....... - -- ------------- <br /> Address.......3.1.4------S-C ...............I,.......I........................................................ ............. <br /> Contractor's Name---OfLA-144.4—.. -------------------------------------------------------------------------- Phone........................... <br /> Installation will serve; Residence'14 Apartment House [] Commercial F] Trailer Court [3 Motel [] Other ❑ <br /> Number of living units: A.... Number of bedrooms ____Number of baths --- Lot size .11--XII/W................................ <br /> Water Supply: Public system 5. Community system 0 Private E] Depth to Water Table -------- ft. <br /> Character of si:41 to a depth of 3 feet: Sand [j Gravel [] Sandy Loam E] Clay Loam [3 Clay,E] Adobe K Ha'rdpan 0 <br /> 'A I <br /> Previous Application Made:, (if yes,clate----------- --------) No 2'00 New Construction: Yes E] No jo FHA/VA. Yes [Ij NoIR <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: -A, Distance from nearest well_________________Distance from foundation....................Material ............................................... <br /> XAI""0. of 'compartments_------------------------Size--------------------------------Liquid depth----------------f--------cap,acity.......1.............. <br /> Disposal Field. Distance from nearest well-_______________ Distance from foundation....................Distance I to nearest lot line............................. <br /> ❑ Number..of lines...................................Length of eachIine_--- Width,of trench.-i---------------- -------------- <br /> ype <br /> ranch.-i-------------------------------- <br /> ype of filter material.........................Depth of filter material-----------------------Total length.......4.................I-------------- <br /> Seepage Pit: Distanc6 to nearest well----------------------Distance from foundation--------------------Distance.to nearest lot line__._.__..__...... <br /> E] Number.of pits----------------------Lining material.—.......------------Size ,Dia6te�r__�,__, <br /> ---------��.l---Depth---._`:_.........I._._.__.._.... <br /> Cesspool- Distance from nearest well-----------------Distance from foundation-------------------Lining material--------------------------------- <br /> ❑ 7Z11— <br /> Size. Diameter_----------------------------------Depth----------=----------------------------------------Liquid C 0.apacity-----'-----------------------gals. <br /> Privy: Distance: from nearest well_________ ------------------------- ..i ---------- Distance from nearest building.........7..�l i <br /> line <br /> -- ............................. <br /> --------- <br /> C1 Distance to nearest lot ...... ------------------------------------------------- ------------------------------------- ................ ------ <br /> Repodeling and Zor repairing (clesctibej----- ------ - ----- .... .... .... . ... ... <br /> ................................!­­---------------........ ---------------- <br /> I <br /> I hereby certify that Fhavo prepared this application and that the wor will be done in accordance with SZ,6 Joaquin County <br /> ordinances, State laws, aArules and regulations of the San Joaquin Local Health District. <br /> (Signed).,�--- - ------- ------------------------------------------------------------I—.........------ <br /> -------------------------------------------I—.................. and/or d/or Contractor) <br /> ------- <br /> By.........................__.-A................... .... .. _.. ------------------------------------------------------------(Title)...................--------------------------------------------- <br /> (Plot plane showing size of 14��(ocation' -o'f system in relation to wells, buildings, etc., can be placed on reverse side). I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATI(3'N� -------------- <br /> ACCEPTED' BY.---..------ -- <br /> --- �----------7----------------------------------- ------- <br /> -- ---- - <br /> REVIEWED-BY" ... I --------------- - ------------1­---------------------------------------------------------------- - <br /> DATE------------- --------------T111 <br /> -------------------------------- <br /> ,BUILDING <br /> ( PERMIT,I.SSJED:___:-..`-- <br /> ---------------------------------............ ..---------------------- DATE--------------I--------------V---------- ...........• <br /> w '­ <br /> Alterations a;d%or reconndrctations:------------------ ------------------ ------------------------------------------------------------------- ......... ................................... <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------......................... <br /> .....................I---------------------------------------------------------------------------------------------------------------------------- ------------------- <br /> --------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- --------------------------------...... <br /> ----------------------- -_------------------ <br /> .................................... ................... ----- -------------------------------------------------------------------------------- .. .... <br /> --- --------- ------------------------------------- <br /> d <br /> ------ <br /> - .. ------- <br /> ------- ---------- <br /> FINAL INSPECTION BY:,�7 ­_ "111111- Date----------- .. <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 /> ES 9 REVISED 6-59 2M 5-451 ATLAS <br />