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FOR OFFICE USE: <br />-------------------------------------------------------- <br /> APPLICATION- FOR SANITATION PERMIT Permit No.---------------- <br /> o. ........................ <br /> (Complete in Duplicate) <br /> Date Issued .... <br />-------------------------------------------- This Permit Expires 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 de cribed. <br /> This application is made in compliance with County Ordinance No. 549. �.J�} : bS7 _ Z_v� -C S' ✓ <br /> 1,517170 A)• r te re <br /> JOB ADDRESS LOCATION. . __ --- -• '� <br /> Owner's Name-- - - ---- ------------------ ---- -- -------- ---- -- ----- <br /> -----------•-------- ------------ P one.................................... <br /> - - - -�-•- <br /> Address lr ----------•--•---------•---•- <br /> Contractor's Name.. _-- v ! s------ ----------------- Phone.._...--------__.-• <br /> Installation will serve: Residence Apart ant House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El <br /> Number of living units: .----- Number of bedrooms _;�n. Number f baths I--- Lot size ------ . -��-------------------- . � <br /> `M <br /> Water Supply: Public system C3 Community system El Private Depth o Water Table -------- ft. I O <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 rrNo ❑ 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 /> Septic ank: Distance from nearest well___s'*.______Distancf from f!ndaticin__L <br /> No. of compartments------A-------------Sizey�?"_�Q-._�__Uquid depth____-Av-----------------Capacity----t_Z <br /> Dispos Field: Distance from nearest well.---._a-----Distance from foundation-----iA___1-----Distance to nearest lot line......---..... <br /> Number of lines----------_.f_ g - �j <br /> ---------- --- Length of each line--------- Q________._....Width of trench----- •.--�.--.---------.-.-.••` <br /> Type of filter material,.,.��.--Depth of filter material------It-i------Total length--------Al------------ <br /> Se a e Pit: Distance to nearest well--- -___Distance from f ndation___._ !7__40_....D�stance to nearest lot line0...�_______ <br /> Number of pits--------/------------Lining material_-.Size: Diameter___2X_ ______Depth_..-___` ____________________ <br /> esspool: 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 /> ❑ Distance to nearest lot line.--------------------------•--------------------•--------------------------------------------------...--------•---------------------------- <br /> Remodelingand/or repairing (describe):-----M--------------------------- -------------------------------........................I----------------- ------..I--- .---------------_ <br /> / r • . r <br /> ---------- <br /> ------------------------------------------M-----------­-------------- -------------------M-------I--------------------------------------------------- ----------------------------- ---------------- <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, Stilla andrules and regulations of the San Joaquin Local Health District. <br /> (Signed]--_------- .------ - ----- ;=" --' jeer and/or Confractor] <br /> BY= •. <br /> � .. . • ----------n-- - - ----------(Title)--_---------=-==----------- <br /> (Plot plan, showing size of lot, location of system in relate to wells, buildings etc., can be placed on reverse side]. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- - - y.: ."i.----------------------------------------------------_--- DATE----/0.71-------rte------------------------------- <br /> REVIEWEDBY---------------------------------F---------- ------------------------------------------------------------------------------•- DATE-----------------------...--------------•---•-------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------•------------ <br /> Alterationsand/or recommendations:--------------------------------------------------------- ------------------------------------.......... ............-----------••----------------------------- <br /> .._..._...-•---------------•--•------------------••---------•---------------------------.-•------------------...------------•-------------------------------------------------------------------------------------------------- <br /> ------------------•---•------------ -•------------------------------------------ f --------------- -------------•----•-••-----------------------------------------------...-------------------------------------I...... <br /> ------------------------------------------------------ <br /> --------------------------------------------------------- --------------- ------------------- --------------------------------------------------- ------•---------------•-----------------------------------------I <br /> FINAL INSPECTION BY:xa - ! ---------------- ---------- -------=- ------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Sveet 124 Sycamore Street .205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 2M 5-62 ATLAS <br />