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FOR OFFICE/USE: <br /> ----------------f...................... -- ----- APPLICATION FOR SANITATION PERMIT Permit No. <br /> -------------- - - --- --- (Complete in Duplicatel f� <br /> ____ ___________.._............ This Permit Expires ] Year From Date Issued 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. W- ,,- <br /> Owner's <br /> JOB ADDRESS AN LOCATION_ _ ____ �'� --� __ �:1f- --.- --��'h- Qs____ � _� _ ._. �'i t°r� <br /> y - <br /> Owner's Name ---- --•----------------------------------------------------------- -- ---------------------------------- ----- Phone_---••---------- <br /> Address-----7f�--AIN <br /> . .: -- ----------------------•-------------.--- <br /> �- <br /> Contractor's Name-------- Phone-----------------------••-.-_----- <br /> Installation will serve: Residence ❑—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _.i7.__._ Number of bedrooms 2—--- Number of baths __2___ Lot size ._�_ ---------------------------------------------------- <br /> Water <br /> et-e, ___________________.__._____._.___-_ <br /> Water Supply: Public system ❑ Community system ❑ 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 U- New Construction: Yes 2-No ❑ FHA/VA: Yes ❑ No [?I- <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 S -__.____._Distance from foundation_1n____---------Material... <br /> __.--------.-------- -__-__ <br /> No, of compartments------.. .........--.Size--------- Liquid depth----- ---- - ..__.Capacity �0'� <br /> , <br /> Disposal Field: Distance from nearest wells_ ---------Distance from foundation_fd_.-_ __.Distance to nearest lot <br /> ®� Number of lines________I-------------------- Length of each line____ ®_ ..............Width of trench._- `---.______________ <br /> Type of filter material_, .I--------Depth of filter material...._ "---.-_. ---- length------- -------------------- <br /> Seepage Pit: Distance to nearest well__eWU_x,/.PC.Distance from foundation-/,,g- ._.Distance to nearest lot line_>fr______..._ <br /> [�] Number of pits----.-J-------- Lining material----- �.�- -.Size: Diameter.----j4_t?_ ----Depth--------4------------------------ <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 nearesf building-------------.------------.-----------_-. <br /> ❑ Distance to nearest lot line-- _ -- - ---- -------- - ------------------------------------------------------------------ <br /> Remodelingand/or repairing (describe):--------- .... . ------------------•----------------------------------------------------------------------------------------------- <br /> -- ------ ------------------ --- ------- -------------------------------------------------------------------------------------------------------------•------ ---------------------------------------------....._.... �i <br /> 1 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 re uia ons of the San Joaquin Local Health District. <br /> ($igned)__________________________________ -..-.-- _ - - {Owner and/or Contractor) <br /> BY:----------------------------------- tr+Ie} <br /> ___ _______�Vi_______________________________________________________________ ------..-____------ ..... .. ..._..__._.._.- <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-- - - --- - ------- - ------ ---------------- -- DATE. (� <br /> REVIEWEDBY-------------------------- ------------- ---- ---- ---- ---------------------------------------------- DATE <br /> ------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------- ------------------------------------------------------------- DATE--------------------------------- <br /> Alterations and/or recommendations---------------- -­------- -- - -- - - _---------------------- ---------------------•---------------------------------------------------------------- <br /> -------------`.---- ---------- <br /> -------------------------------------------------------------------------------- <br /> E. <br /> ----------------------------------------------✓ -- <br /> FINAL INSPECTION BY:.�"_ <br /> z . __�__ Date........./= - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 144 Sycamore Street 205 West 4th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E9.9 REVISED 19-59 F.P CO.2M 6-6p <br />