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FOR OFFICE USE: <br /> -------------------- ------------­-- ---------- <br /> ........ APPLICATION FOR SANITATION PERMIT Permit No. ......................... <br /> ---------------- .... .. <br /> - -,.I--------- -------- (Complete in Duplicate) <br /> .......... - ------------ . ........... This Permit Expires I Year From Date Issued Date Issued ...............------- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constr ,yrrstall the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AICD LOCATION.,_-�------------ <br /> Owner's Name__. `.__: <br /> --- <br /> ------------------ <br /> --------------------- ------------------------ Phone ---------- <br /> Address ------• -------- ---------- .......... ...... <br /> ----------- <br /> Contractor's ----------------- --------- ------------I---------- -----------------------------------------......... Phone................................... <br /> Installation will serve: Residence Apartment-House [] Commercial C1 Trailer Court E3 Motel [I Other ❑ <br /> Number of living units: _--1_._ Number of bedrooms _2�_ Number of baths Lot size <br /> Wafer Supply: Public system E] Community system [] PrivateEl Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand FAdobe <br /> - ayE] [3 Hardpanc] <br /> GravelL] SandyLoamlE Clay Loam ❑ C <br /> d <br /> Previous Application Made: (If yes,date--- ----- ---- No [M New Construction: Yes No Ej FHA/VA: Yes E] 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---D�---_---Distan�e from foundation__.1A----------Maferial__16_0�---------------------------------- <br /> V1 No. of compartments-------,>x------------ ----Liquid dep�h----------q__........Capacity.1-2t.ft <br /> Disposal Field: Distance from nearest well- �P------._Distance from foundation---JP------------Distance to nearest lot line-...,§......... <br /> 50 Number of lines-----3--- - ---- --__Length of each line-----Y_C?----------------- <br /> -.Width of french.- _':.•----------•-____-- <br /> Type of filter material <br /> - ' --Depth of filter material-----11,11---------Total Iengfh__?-_44----------------------------- <br /> Seepage Pit: Distance to nearest wO----------------------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 /> 171 Size. Diameter------------ - -- ---r------------.,--Depth-.------------ --------------------- ---------------Liquid Capacity--------------------_------gals. <br /> Privy: Distance from nearest well - --------------- -------- ------ ...Distance from nearest building------------------------------------------ <br /> El Distance to nearest lot line-- ------- ----------------- <br /> Remodeling and/or repairing (describe)--------------------------- --- ---------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I-------- <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 Joaquin Local Health District. <br /> (Signed)---------%­---------------- ------------------ <br /> --------------- ---- -------------- --- ------------------------------------ ----------------------- -----------(Owner and/or Contractor) <br /> By:--------• ---------------------------------------------- ---- ----------------------- ---------------------------------------------(rifle)------------------- ------------------- ............. -------- <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 ----------------- ----------- <br /> ------------------------------ DATE__1 <br /> REVIEWEDBY----- ------------- ------------- --------------- -------------------------------------------------- DATE ----------------------------- <br /> ------------------------------ <br /> BUILDING PERMIT ISSUED-------------------------- ------------------------------------------------------ ------------------- DATE.-------------------- <br /> -Alterations and/or recommendations:,----------------------- <br /> ------------------------- ------- -------I---------------------- --------------------------------- -------- --------------------------------- ----------------------------------­----------------------------------------- <br /> --------------------------------------- -------------------- ------------ ---------I-------------------­�--------------------------------------1------------------ -------------------------------------------------I.- <br /> -------------------- ---------------- --- -------___......... ....... ---------- ---------­_- ­-------- ------------------­ ....... ---------------------- ------------- .....................---------------- <br /> - ------------------------------- --I....... -- ------- --------- ------ - --------- --------------------- ---------------- ------------------- ---------------------------------------- ------------FINAL INSPECTION IRY:.Z,/' -------- -------- -- ----------- Date..:.....:-". --------- <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 Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 2M 5.61 ATLAS <br />