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FOR OFFICve, <br /> USE, <br /> q3 <br /> � _------- APPLICATION FOR SANITATION PERMIT Permit No. ._.�--------:--- <br /> - -------------- -- ---------------------- <br /> --------------- <br /> -------------------------�=---------------------------- (Complete in Duplicate) 3 <br /> 4 Date issued <br /> ..=..�"---------------------------- - ------ This Permit Ex ires I Year From 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 /> S2/:k <br /> JOB ADDRESS AND LOCATION.- --____-- -'--=------------ -- -------------------_--------- <br /> Owner's Name--------,___!1----a` -- . �J�.[�»2Phone - <br /> --------------------------------------------------------------- --------- <br /> r - <br /> Address.- °rij-'� -------------------------------------------------------=-------------------------------------------•- <br /> a s- <br /> Contractor's Name-------------- ----------•---- ----,7.5, ------ Phone.-------- -------.................. <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___2____ Number of bedrooms __?:.__,Number of baths --- Lot Lot size _____.6d__�__�-�_________________________________ <br /> ( Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 6.0_ ft. <br /> Character of soil to a depth of 3 feet: Sand F] Gravel ❑ Sandy Loam El Clay Loam ❑ Clay [❑ Adobe 8--­Harcipan ❑ <br /> Previous Application Made: (If yes,date___________ ------_) No-® New Construction: Yes nr-No ❑ PH./VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 4 <br /> I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - `-- - - <br /> Septic T nk: Distance from nearest well___'__``__-.__Distance from foundation___�_o__-________-Materiai---_-_!-`��"°�.o__�_________________ <br /> I [� No. of compartments-----.2-'------------"__:Size=_v-=3'�_3_x_�___.___Liquid depth__''_- --------,Capacity__t�a��_._ <br /> - k ; <br /> Disposal Field: Distance from nearest well.__"'_____"__Distsnce from foundatiolgt------------Distance to nearest lot line---S__ __.. <br /> [� Number of lines-------------� ---------Length-of each line------��--1--------_------.Width of trench_.Z`Cg------------------------ <br /> Type of filter material_ 4` ____ ___Depth of filter material----L$_'-----------Total length_-__-_-90----------------------------- N <br /> Seepag it: Distance to nearest well----__-__________Distance from foundation----�q..........Distance to nearest lot line-_�___._�._._. <br /> Number of pits------'�-------- - Lining ma+erial �C_ -____...Size: Diameter__ 3- Depth___ __'_______________ <br /> t Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-- <br /> Size: Diameter------- -----------------------------Depth----------------------------------------------------Liquid Capacity- ----------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____________---________--- <br /> I - <br /> Distance to nearest lot line --------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)---------- -------------------------------------------------------------------------•'-•--------------------------------•----- ---•---•------------------ <br /> -------------------------------------•-------------------------------------------------------------------------------- _ <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 laws, and rules and regulations of the San:Joaquin Local Health District: <br /> r � - <br /> ?. (Signed)------------------------ ------------------------- --------- ------ ---------- ----------------------------- ---------------------------------------.(Owner and/or Contractor) <br /> 1 BY--------------------- ----- ------- --- - --- ( ) <br /> -------- --- ------------------------------------------- Title <br /> (Plot plan, showing sire of lot, loco ' of sys+em in rel tion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- .......------------------------------------------------- DATE---------19 <br /> REVIEWED BY------ --'-------- ------------------------------------- DATE-------------------------------------------------------------- <br /> ------------------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------------------- DATE----- ------------------------------------------------------ <br /> Altera#ions and/or recommendatio ------ --- <br /> y�- _. , -------------- - -------------------- -' --- --------------------------------------- <br /> ------- ---. <br /> FINAL INSPECTION BY:- --------------------- Date_ " j- ---------------------------------------------- <br /> SAN <br /> . ' ' ' ' r ' <br /> C-.-- G - ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 1:.Hazelton Ave. 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•S9 3,.9 3-'63 F.P.CD. ' <br />