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FOR OFFICE USE: <br /> -------------------------------------- ----------------- <br /> � 1:APPLICATION FOR SANITATION PERMIT Permit No. ..��.�`..1�..� <br /> --- --- --- -- ------ (Complete-in Duplicate) a <br /> - _ _._ --___ ------ This Permit Expires 1 Year From Date Issued <br /> Date Issued --- <br /> � <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. y� <br /> JOB ADDRESS AND LOCATION_.- ,�- - �tl��1 -------------- -------r-- - ------------------------------------------------- <br /> Owner's Name ---- ---•---rr,rL�Y '` ---------••---------- ------ - Phone.................................... <br /> Address----- ......................00 if.�.-- - <br /> Contractor's Name__,J4.9'±t`*------------------------------ --------------------- ------------ ------- ---------------------------------------------- Phone------ ---------------------------- <br /> Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: j..... Number of bedrooms 7�----- Number of baths_-.� _. X 1 Z � <br /> .__ Lot size t. __-_ - -------------------------------- <br /> Water Supply: Public system M Community system E] Private ❑ Depth to Water Table ------ _ ft <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 ❑ 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_004"4__.__Distance from foundation__%y_---------.Material ---L`Wx.''_`!' '________________________ <br /> No. of compartments_.A"__._----___----_-Size_ . " _. f__`r-----Liquid depth-----9�------. .------ Capacity_1Z_"__----- <br /> Disposal Field: Distance from nearest well_-/r"' _4--- -Distance from foundation_.?-;7...........Distance to nearest lot line.. �____--- V <br /> Number of lines_____-I--------------------------Length of each line__ ___l_6---------.--------Width of trench-.. _y_°"__-____-_-_-_______ <br /> Type of filter material_k_ ----------.-._Depth of filter material__/_ F_____.------Total length__./aP!_____________________._-____ <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----------------------------._____-__ <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 /> 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, a d rules and regulations of the San Joaquin Local Health District. <br /> (Signed).- -t ;d .• _ -------------: --------------------------- ----------- ------ ------------(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 /> �J FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.__-- <br /> ---- -- - -- - -------------------------------------------------------------- DATE--"_%-jV-- -------- <br /> ------------------------- <br /> REVIEWEDBY------------------------------------------------------------------ ------------------------------------------- -------- DATE---------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------- ----------------------------------------------- DATE-------------------------- <br /> Alterationsand/or recommendations------------------ ----- -- ---•--------_-----•-- --------------------- ---------------•--------------•------------• ---------------------•----------- <br /> ------------------- ---------------- ----------------- -------------- ------ -------------------------•---------•----------••----------------•- <br /> ---------------------- -------- - --------•----------------------------- ------------------------------------•----------•-----------•-------•------- •------------ <br /> FINAL INSPECTION BY:..-�__ .t to Date_.-t�`- '6�C <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 /> E.H.9 2M 1.67 Vanguard Press <br />