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�FOR OFFI USE: <br /> -G--- --------------. <br /> APPLICATION FOR SANITATION PERMIT Permit No <br /> -------------- --------------------- -- / <br /> _-- . , .r. <br /> --------- ------------------------- --- - -------------- {Complete in Duplicate) �! 37 <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 Ordnance No. 549. <br /> JOB ADDRESS AND LOCATIC�7N.____ ___ ---- -- --- <br /> I f ................... <br /> tOwner's Name__ - -------- - -----� ``-------.---- ------------------------•--- Phone------------------------------------ <br /> Address--_------- <br /> ----------------•-•----------------Address--•-------- ............. ---- _---------- <br /> Contractor's Name---- . PhoneC------L <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [Motel ❑ Other ❑ <br /> P <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size /. .. ................................. <br /> Water Supply: Public system Ll Community system E] Private .&_ <br /> Private [ <br /> pth To Water Table pft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobd-f:rHardpan ❑ <br /> Previous Application Made: (If yes,date-..--- -------------) No [ New Construction: Yes gil< ❑ FHA/VA: Yes ❑ No <br /> t <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> l Septic ank: * Distance from nearest well---------------__Distance from foundation.-------------------Material-----------._..-__.____.______-.•--_________----. <br /> E' No. of compartments-------- ----------------Size--------------------------------Liquid depth-------------------------Capacity--------•--------...e <br /> Dispos Fief Distance from nearest well_._r.-Distance from foundation._,���_.`...__.Distance to nearest lot line-.Lv°_______ <br /> ��� Number of lines______.______ Length of each line__30--_`_______________Width of trench.__:-.4.'�-_�__.____.____----- <br /> i <br /> Jf Type of filter material.....---- /I <br /> Type of filter material-___ ....Total length._._..-�,3___�............................ <br /> Seepage it: Distance to nearest well_1_ilh__________Distance from foundation._'."....___.Distance to nearest lot line_�d�t__..... <br /> '� r. .. Depth------ �'-�_-------- <br /> Number of pits.____:'-------_------Lining matanal___`%�a��'C__.Size: Diameter__ .: _-_._-.___.._ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining <br /> l material--__.---___--__-____.__________------ <br /> ❑ Size: Diameter------------------------•------------.Depth----------------•--------------- - ---------- -_Li Liquid Capacity....----_---------------- is. <br /> 4 <br /> Privy: Distance from nearest well-_________________________.__________._ -------Distance from nearest building------------------------------------------ <br /> 11 Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe)-----------------------------------------------------___-----------------------------------------------------------.----------------•---------•------- <br /> C -----------------------------•--------•-------------------------......-----------------------------------------------------------------------------------•--------•------------------- _------------------------------------ <br /> -------------•---------------------------- ----------------------------------------------------------------------------------------------...------------------------------------------------------:.._._-._------------ <br /> hereby certify that 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 regulationsWtheSlauin Loc Health District. <br /> (Signed) - ---------------•------•------------------ ----------- (Owner end/or ContractorBY------------------•-----•----------------------------------------- --- ------------------------------(Title)---------- ------------•-------- .................... --------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> f <br /> : FOR DEP RTMENT USE ONLY rr <br /> APPLICATION ACCEPTED BY " -- -------- -------•------------------------ DATE----- ---- `� 4 <br /> REVIEWED BY------------------------------------------- �.. <br /> --------------------------------------- - .._...... ---------------- DATE---------------_--.....---------------••------------- <br /> BUILDINGPERMIT ISSUED-----------------------------------------------------------------..------------------......--•------- DATE--------------------------------- --------------------..----- <br /> Alterations and/or recomm ndations___________ _______________T _____ <br /> ------------------------------ ------------------------------------------------------ -------------------------------------------------------------------------------------------------- ------- d` <br /> ------------------------------------------------------------------------------------------.----------------------------------------------------------------------------------------- . <br /> ----- - <br /> FINAL INSPECTION BY:--- ' � --------- 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 /> £S 9 REVISED 8-59 2M 5-62 ATLAS <br />