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FOR OFFICE USE:' y <br /> --------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. _.. .T. . a� <br /> ----------------- ------- ----- --------- -------------- (Complete in Duplicate) y��1 <br /> --------------------------------------------------------- This Permit Ex ires 1 Year From Date Issued <br /> 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 LO A 10t = � - ----•------•---•------------ <br /> . ---- _ <br /> Owner's Name -. -------------- Phone------------------------- <br /> Address <br /> _.. <br /> Address__--------••-lr t7....G4/,. ------------------ ---------------------------------------------------------------•-••--••-----------------------------........_.. <br /> Contractor's Name--------------- _-_ .� ..__..__ Phone.:'-'...------------_--_ <br /> Installation will serve: Residence// Apartment House ❑ Commercial E] Trailer Court L] Motel El Other E)Number of living units: ..!---_ Number of bedrooms __ate_ Number of baths _/l__ Lot size , :1x�__ <___--_____-.-_ __________________ <br /> Water Supply: Public system [Community system ElPrivate [j Depth to Water Table f- pft. <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 [Lf'New Construction: Yes Hj--f o ❑ FHA/VA: Yes gj--TVo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool"permit+ed if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well____,—::____-__Distance from foundation---- �_.______.MatG Material----- _._-_._._.__ <br /> D[� No. of compartments-----�---------------Size_��.?_<__��----------Liquid depth----//__�_a---------------Capacity...- -f-•-------••- <br /> Disposal Field: Distance from nearest well_._._ --------Distance from foundation-/ .__.......Distance to nearest lot line__a�_`----________ <br /> Length of each line___________ <br /> Number of lines___.__i�-______--..______ >���_________-Width of trench_____ ------------------ <br /> Type <br /> ___ _____________ <br /> Type of filter material/ ----Depth of filter material---4!�'__-------Total length- --- ------------------------- <br /> See�a.,`e Pit: Distance to nearest-well_____________________Distance fr m foundation___1P_�__._.-Distance to nearest lot line_-j----- <br /> LR Number of its----- -__ - / 224-- —� <br /> p' �_-----____Lining material-- -_ .per/'___.Size:.Diameter-224___ ________Depth__�..�I� ___.____.______ <br /> Cesspool: Distance from nearest well _____-----------Distance from foundation-------------------.Lining material...-.______________--__.________.___. <br /> ❑ Size: Diameter--------------------------------------Depth_ --------------------------------------------------Liquid Capacity-----------------------------gals. <br /> Privy: Distance from nearestrwell__________________________ ______________ Distance from nearest building--------------------.-__._____--_._-.--._. <br /> ❑ Distance to nearest lot line--------- - ------- --------------------------- -•--------------•--------I-••--------------------._---------------------------------------- <br /> Remodeling and/or repairing (describe)-- !---- ------- &A4� <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --- -----------------------------------------------------------I——---I-------------­------------------I--------------•------------•--------------- --•--------------I•------- ------------- - <br /> I hereby certify that] 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 /> (Signed)----------------------------- rU Contractor) <br /> B ---------------------------------------- <br /> (Plot <br /> - ------------ ---- <br /> • � [Title}___ /i'f/tf' <br /> (Plot plan, showing size of lot, location of system • elation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY------- y-- - -- ----- - ------------------------------------------------ DATE-------fit--1_.ef--------------------------- <br /> REVIEWEDBY------------------------------------ ----- ------------------------------------------------- DATE --------------••---------------••------- ----------- <br /> BUILDING PERMIT ISSUED-----------------------------------------------------------•------------------------- --------. -. DATE------------------------------------------------------------ <br /> Aiter ion and/or recommendations:__--- ------- ------------ -------- -------------------••- -••----- -•-----------------------••-----------•--------•----•--•----•-------------------------- <br /> 9 ••-•----- <br /> ----- ----- <br /> ----- -------- �<-- - - - ---- <br /> je� <br /> FINAL INSPECTION BY:.. _2� ----� �___ ------ Date-- f ----- ----------------------------------------- <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 /> EP-9 REVI6E0 0.99 r.R.00.2M 6.60 <br />