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FOR OFFICE USE <br /> / �.,+ , � � � �, G c*,l ,fy f-e-w op, v-•�- <br /> lAPPLICATION FOR SANITATION PERMITr141-nit No. <br /> ---------------------------------------- ------------ (Complete in Duplicate) <br /> Date Issued ...�./��....��./ <br /> _______________ This Permit Expires 1 Year From Date issued <br /> Application is hereby made to the San Joaquin Local Healfh District for.a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 4�9 <br /> JOB ADDRESS AND CATION ..._�.. __ Gly <br /> Owner's Name------------ -------- - •- -- -- - ------- Phone------------------------------------ <br /> Address------------------------ <br /> -------------------- - - <br /> Address � ... _ ------•--•--•---------- <br /> --- <br /> .._-_...__ Phon Z_A .. <br /> Contractor's Name ` ... <br /> Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _/__ Number of bedrooms §;_ Number of baths ./_- Lot size __- C_________________________ <br /> Water Supply: Public system ❑ Community system ❑ Private Er""Depth to Water Table 41A ft. <br /> Character of soil to a depth of 3.feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: (If yes,date-- ] No ❑ New Construction: Yes ❑ No U4-`_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 /> ti Tanta: Distance from nearest well __-__.--______-Distance from foundation...........---------Material____-___-________-_____-__-_---._-_____________- <br /> No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> "Id: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_-_.--__-________ <br /> ❑ Number of lines-----------------------------------Length of each line----------------•------- -----Width of french----------------------------------- <br /> Type of filter material-----------_-------------Depth of filter material-----------------------Total length_-___.__-________-_________._._-_____.-__ <br /> Seepage Pit: Distance to nearest well---/lop- -------Qistanc om®/ foundation__s3Q.__ .�,� _.-Distance to nearest to line__.._..__-- <br /> _ _ n ,Number of pits__.-___�______- __Lining mataaL_._ -D_C`' Size: Qiameter____ ._ ____.Depth_.__.- -- ,�_ <br /> - _______________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---_----------- ----Lining.i:material-_:------------._-_____.----_________- <br /> r <br /> ❑, Size: Diameter---------- ---------------------------Dept h---•---------------'---------------------------------Liquid Capacity------------------------------gals. <br /> `Privy:' Distance from nearest we'll___y--__.__s___ --------------------------------Distance from nearest building------------------------------------------- <br /> ❑ Distance to nearest..lot line-----------------------•---------------------- ------•= --------•------••-----••------------•- ---------------•--------------- <br /> Remodeling and/or repairing describe :______-_________________.--------.--------------------- <br /> ------------------------------------------------------------------------------------------•----•------ ------------------•----------••----------------------••--------------------------- _------------------ <br /> ---------------- ------------- -----------•-------••------•-------------------------------------------------------•----------••------------ 7y--- <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, St a laws, and rules and gulations of the San Joaquin Local Health District. <br /> 4(Signed) ---------------------- ---- (Owner and/or Contractor) <br /> Title <br /> B . ( ) ----------------------- <br /> (Plot plan, showing size'of lot, location of system in relation to ldings, etc., can be placed on reverse side). <br /> ! FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------- - -tv- - ---I---le------------------ DATE------------ r <br /> REVIEWED BY = ------------------------------------ DATE ------------------- <br /> BUILDING PERMIT ISSUED-----------------------------------------------------------------------------------------------------• DATE <br /> Alterations and/or recommendations:------.-------_------------- - <br /> ---------------------------------------------•----------•-•-------------------------------------------------------------•---•---•---------•----•-•--------------------------------•---•---------------•--------------- <br /> -------•-•--••----•-------------•-----•----------------•-•--------•--------------•--------------------•-------------------------------------------•--•_.---_--------------------------­­ -----------------------=--•--- <br /> YY <br /> { ___________-----------------------------------_----------------------------__----_________---------------------------------------------------------------------------------------------.---__---___-_-__-_-_______-___-_-..... <br /> f <br /> G FINAL INSPECTION BY:-------- <br /> 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 Tray,California <br /> EB-9 REVIBE13 13.59 F•F.0O3 ZM 6-60 <br />