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FOR OFFICE USE: <br /> --� ----------- Permit No. .����---� <br />------------------------------._--.----- APPLICATION FOR SANITATION PERMIT <br />------------------------------------------------ <br /> --------- <br /> ! -- _- - ----_- (Complete in Duplicate) Date Issued -�.-��--- <br /> ----------- ----------- <br /> --------- <br /> ---=----- <br /> --- ---- -------- - <br /> ------.- This Permit Expires 1 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 described. <br /> This.application is made in compliance with County Ordinance No. 549. � ; Q /7 -- 21Fa� Z2. <br /> lwb'`�zs - ; � <br /> — <br /> ------------------------, <br /> LOCATiON.1 •�-' <br /> JOB ADDRESS AND --. Phone-------------- <br /> ----------------•---- <br /> Owner's NamO ------------- ---- ---- •-� ----- j <br /> ®� � <br /> `TM � ------------------------­------------------••----•-----------•........... <br /> Address---------- ....... ------------------- <br /> ---------------� <br /> Contractor's Name.-.. --------------- Phone-•-•-•----....-------.--------• - <br /> ----- <br /> I Installation will serve: Residence ❑ Apartment.House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: ----- Number of bed rooms_.__--'•Number of,baths Lot size ------------------------- <br /> Water Supply <br /> li : Public sy stem [K Community system ❑ Private ElDepth To Water Table -------- ft. <br /> I' <br /> Clay Loam [3 Clay ❑ Adobe❑ Hardpan C]Character of soil to a depth of 3 feet: Sand [I Gravel El Sandy Loam [ <br /> El <br /> Previous Application Made: (If yes,date---------- ----- ---) No El New Construction: Yes E] No [3 FHA/VA: Yes E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspaol permitted if public sewer is available within 200 feet.) <br /> i <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material..------------------------- <br /> ; <br /> No. of compartments------ ----------- ----Size.---------•----•------•--. ---Liquid depth----------- --------------Capacity-----•--------f...---- i, <br /> ❑ <br /> Dispos Field: Distance from nearest well Q--_._..Distance from foundation...-IQ--------••Distance to nearest low line-.-5........... <br /> Number of lines-----------i---�-----`--�---r�----•--Length of each line-------�-Or� .....;------Width of french_..2r.----�...----'--------•---- <br /> Type of filter material....l—{G------•Depth of filter material--------12--___--.--.Total length------- SP-----••-----•-----••---•-- <br /> Seepage Pit: ,..t ' Distance.to nearest well-_-------------------Distance from foundation---..__-...._. <br /> --..Distance to nearest lot line------------- -- <br /> ❑ --------Depth-------------------------------• ' rh <br /> i Number of pits-_------------------Lining material•-__-_---_--- -------Size: Diameter <br /> Distance from nearest well.................Distance from foundation----..-------------.Lining material..---------------------------------- <br /> Cesspool- <br /> --------- I <br /> ,❑ ! Diameter ----------..Depth------------------------------------------------ <br /> Size: Liquid Capacity 9 <br /> ---Distance from nearest building--------•----------•----••------•--------- <br /> Privy: Distance from nearest well----------------------------•-------- ----- - <br /> d.. -------------------------------------------- <br /> ❑ 'pistance to nearest lot line----- ----------- ---------- ---------•----------------------•--------------------••---•-------- <br /> . ,ems B '1---------------------------------------------------- <br /> and/or repairing describe .-"..C.. <br /> i�emrSde�ITrry- / p 9 � • ��-------- ------ - ------,------ ---•--- -•---•- _ <br /> --•-F-`' ---....---•-•----'•-----y -....----'--- '-- '""`� ----------------•-•--•-•-------•-----------••----••-------------------•----------....--•----...-..-------•-i-•----------...----------»-----....--..------.. <br /> a <br /> s <br /> hereb" F; ti --------- <br /> y certify that I have prepay''F�this"applice+ion and That the work will be done in accordance with San Joaquin County11 <br /> ordinances, State laws,\i-,\iregulations of the'San Joaquin Local Health District. , <br /> -------tewm and/or Contractor) <br /> ------------------------------ <br /> -------------- <br /> [Signed <br /> I ------------ <br /> By:' ,>�r ' - ------------------------------------•- (Tit e} = -. <br /> (Plot plan, showing size of lot, location of system in re ation to wells, buildings, etc., can be placed on reverse side).' <br /> FOR DEPARTMENT USE ONLY <br /> I _ /s G.3 - ---- r <br /> APPLICATION ACCEPTED BY ------------------- DATE - V <br /> ' ------- DATE--- --------=-------•-•---------------------- ---- ' <br /> REVIEWEDBY---------------------------------------------------------------- --------------------------- -'----------------- <br /> BUILDING <br /> . , <br /> BUILDINGPERMIT ISSUED-------------------------------•-------------------------------------------------- <br /> Alterations and/or recommendations:..-------------------------------------------- ----------•--------------••----- <br /> I �--------- ------- ------Y...-------------- --------- <br /> ------------- ---- <br /> �L ,_ a... Date....��--------•�-._..-------•---------- --------------- ---------- -------- <br /> FINAL INSPECTION BY• - .- -- --� <br /> .--. `----------- ------------- <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300.West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California <br /> Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 8-59 2M 5-62 ATLAS <br />