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FOR OFFI E USE: <br /> ------------------- ______________ APPLICATION FOR SANITATION PERMIT Permit No. ........... <br /> ► -------------------------------------------------------- (Complete in Duplicate) / —.�/ 3 <br /> ------------ -------- This permit Expires 1 Year From Date Issued Date issued .................... <br /> Application is hereby made to the San Joaquin Local Health District fora 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 LOCATION rzZ.+ I �115_T0IV YC. ' ---------------------------------------------------- <br /> Owner's Name---- <br /> Address --------------------- •------------------------------------------------------ ----------------------------------------------------- --------- <br /> Contractor's Name------ Z/-V--C'------- Phone/Te. .111.. d1 y7 <br /> Installation will serve: Residence Er-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> I Number of living units: I---- Number of bedrooms _2— Number of baths _1____ Lot size ------ -----------------­-- <br /> Water <br /> -_______________ __Water Supply: Public system 1�1- Community system ❑ Private ❑ Depth To Water Table d-P it. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam g--'Clay ❑ Adobe�ardpan ❑ <br /> Previous Application Made: (If yes,date__---4._------------) No ew Construction: Yes ❑ No ®�'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 Tank: Distance from nearest well_________________Distance from foundation--------------------Material--------------------.__________--_____----__..__. <br /> ❑ No. of compartments------ ---- --------------Size----------------------------_---Liquid depth---------------- ---------Capacity-----•---------------- <br /> Disposal Fiel . Distance from nearest welf_fV.6.61.1 Distance from foundation-1 .............Distance to nearest lot line----Y / <br /> ___. <br /> ® Number of lines_-_----f--------------------Length of each line......... of trench___._____2-._C.`_---------- <br /> Qt-01 Type of filter material..�f?: C� Depth of filter material------L ,_��_._.-Total length___..._..._..-0------------------- <br /> Seepage pit: Distance to nearest well-.--------------------Distance from foundation--------------------Distance to nearest lot line__.-____.. -_.. 1" <br /> ❑ Number of pits----------------------Lining material---------.-------------Size: Diameter-----------------------Depth_-----------------•------------ <br /> r 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 /> ❑ Distance to nearest lot;lin_e- ------- ------------------------------------------------------------- ---------•-•--------------------•----------------------- ------------- <br /> I <br /> Remodeling and/or repairing (describe)___/ ,O._.__7`�7-.---Ej1�ls.fes/N- ___s�°`Y�S' E/ J__----------------------------- <br /> ---------------------------•------- ----------------------•----- -----------------------------------------•---•-----------------------------.----------------------------------------------------------------------------- <br /> -----------------------------------------•-------------------------•- <br /> 4 ` .-______________________-__--.______.._____-_____--_-..____------...-_ <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 /> (Signed)-------•-- - - ------ --------- ---------------------------low. or and/or Contractor) <br /> ------------------------•----------------------------(Title)---------- --------- ---- ---._._..--------- <br /> (Plot plan, showing sire of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 4 l <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -- -- ---� ��L— ----------------------- DATE.... <br /> f ------------------ <br /> REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------- DATE------------------------ ------------•-- <br /> BUILDING PERMIT ISSUED--------------- ---- -------------------------- DATE...--------------------------------- <br /> Alterationsand/or recommendations:-------------- -------------------------------- -------------------••-------------------------------•--------•-•-------•---•---•------------------------ ------ <br /> -------------------------------------------------------------------•------------------ --------------------- ----------------------------------------------------_.._... -------------------------------­------------- <br /> --------------------------------- <br /> ------------- <br /> -----------------------•----------------------•-------------------•------------------- ------ --------------------------------------------------------------------------------------------- -------------------------------- <br /> r FINAL INSPECTION BY:.- - ----- �ry ------------ Date.-----/----- = <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> } Stockton,California Lodi,California Manteca,California Tracy,California <br /> Es 9 REVISED 11.59 2M '5-62 ATLAS <br />