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FOR OFFICE USE: <br /> --- ---- --- - -- ------- ------ -----------� <br />------------_-----------------------------------_ ...... APPLICATION FOR SANITATION PERMIT Permit No. ..�`,1(... .! <br />----------------------------------------- --------------- (Complete in Duplicate) L Z--- <br />----------------------------------- <br /> --------------------- This Permit Expires 1 Year From Date Issued Date Issued 1 ...�� _ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons uc and nstall the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS ANDLOCATION *!k �°�!' �1 .......... <br /> Owner's Name........ .li-'2 --------1 -------------- Phone-f!-------77..5 .13. <br /> Address.............. -------- S— <br /> Contractor's Name--- ----------•----•-------------------------------------------------------------------------------•-•----•----•--- Phone................................... <br /> (nstallation will serve: Residence ,( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ._____ Number of bedrooms -__1--Number of baths __,1. Lot size ......Zp_k-t..1-X'0............................. <br /> Water Supply: Public system ❑ Community system ❑ Private [E Depth to Water Table 4.6-_- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam IX] Clay Loam ❑ Clay❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No ® New Construction: Yes X 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__c;�_b-------Distancg from foundation....1a...........Material__.......?'.t4 ..................... <br /> f$J No. of compartments----;-L..................Size_'f .......Liquid depth_..._y__-____-___._--_:Capacity.. .............. <br /> Disposal Field: Distance from nearest well__Sd._____._Distance from foundation-J ............Distance to nearest lot line.....C........ 4 <br /> Number of lines.........../-----------------------Length of each line-----/./_:Q...............Width of trench....0.4.--.''._---- <br /> *.............. <br /> Type of filter materia] '. -Depth of filter material...___I- ------Total length...24A.............................. <br /> Seepage Pit: Distance to nearest won-______________________Distance from foundation....................Distance to nearest lot line................. <br /> ❑ Number of pits______________________Lining material.......................Size: Diameter........................Depth................................. <br /> 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 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 Joa u' Local Health District. <br /> (Signed)--4 _e, I-.. .._ , .........................................................(Owner and/or Contractor) <br /> By:..................... -------------------------------------------•-----------•-----------•---------------------------•-----------(Title)-•---•------•-----•-•--•---- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ _ •- -Z'_•.-__----_--- <br /> ---------- ------------------------•----------- DATE.. _. " . <br /> REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE............................................................ <br /> BUILDINGPERMIT ISSUED..............................................................—...................................... DATE............................................................ <br /> Alterations and/or recommendations------------ ----------- -------------------------------•-•-•---•---------------------------------•------------------.....------•---••......•-•--•---••--•------ <br /> ................................................--........................................................................................................................................................................... <br /> •---••-----•--------•-•--------------------•--•-•--•--••-----••---•---•------------------•--•--•••••....------••-----•----•-----•-•---•-•--••--•••-••-••-•--------------•----•----•-----•--••------•••----•-•-----•-----•---- <br /> ---•------•--•-•--•-------------------------------------------------------------------------------- ......................................... ----------------------•--••--••----•--•-•-•-•--•--•-----•-••......- <br /> --------------------------------------------------------------------- ----------­---------------------------------------------...------------------------..._.._..----------........._......--------------------•........... <br /> p�r <br /> FINAL INSPECTION BY:.,�� - • ---------------------------- Date----tt=---1.,�. ................................................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Strout 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 5-59 RM 5-61 ATLAS <br />