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FOR OFFICE USE: <br /> --------------------------------------------------------- `\ <br /> ------ <br /> PLICATION FOR SANITATION PERMIT Permit No. .. yi3s <br /> --------------------------------------------------- <br /> --------------------------------------------------------- (Complete in Duplicate) <br /> ��� .-� 1/----- S <br /> ______________________________________________________ This Permit Expires 1 Year From Date Issued V 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 L CATION. _ _______________________________________________ <br /> ..... <br /> Owner's Name--- Phone <br /> Address :_ .. ....... ® j _ 1 <br /> Contractor's Name--------- ,c• -�t.� 1_�--' —f C=� o ---------------•------------------------------------ Phone. <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: A____ Number of bedrooms ....I.. Number baths _.l___ Lot size __.__ ................. <br /> Water Supply: Public system ❑ Community system [1Private /Depth t Water Table ........ ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑- Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If'yes,date------_____-______) No ❑ New 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 ank: Distance from nearest well '�______- �__Dis# cr_e from ffoundation_____t _�......Material____-eend_________________________ <br /> No. of compartments------.9- __Size_ --- __Liquid depth__.� _ <br /> -------- ------Ca acit ©v ___ , <br /> Dispos "Field: Distance from nearest well___. ?_'._Distance from foundation____._e'_`_.__.Distance to nearest lot line_S' <br /> Number of lines------------- <br /> I-- --------------Length of each line------J_C_E_:'__-_________-Width of trench----o---- _,_____________________ <br /> Type of filter material___._�V_�----------Depth of filter material------1_L_�_-____Total length.......LP0_________________________ <br /> Seepage Pit: Distance to nearest well........_-------------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------------------------------------- A <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building............................. 0 <br /> ❑ Distance to nearest lot line-------------------------------------------- - - ----------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):--------------------------------------------------------............... :: <br /> ------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------- ----------------------=-4E ------------------- <br /> - ------------------ ------------------------------•---------------- ---------------- -- -- <br /> ---- ------------------------ --- -------------- ----------------------------------------- ----- -- ---- ----- ----- -----•-------- - ---- -- ----------------- ---- -- -- - - 1 <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 /> n1. <br /> (Signed �--'----- - -----------------­---------- and or Contractor <br /> BY:-------------- = - -_ (Title) - <br /> (Plot plan, showing size of lot, location of system ,n elation to ells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ----------•--------------------------------------- DATE.----4.. -------------------------- <br /> REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------• DATE----------_--------_----------•----------------------- <br /> BUILDING PERMIT ISSUED..........--------------------------------------------- -----—...................................... DATE-----------•---- <br /> -------------------------------------------- <br /> Alterationsand/or recommendations------------------------------------------ ----•--------------------------.............................................................................. <br /> ------------- ---- ------------------------.................................................................................................................................................... ---••-------------- <br /> -----•---------- -------------------------------------------------------------------- -----------------------------------------------------------------------------------------------•-------------- -------------------- --- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------•---------------•---------------•--------. •-•------------------- <br /> FINAL INSPECTION BY'/;ems y ----------- Date__b.'� '- �'� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 3M 3-'63 F.P.CD. <br />