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FOR OFFICE USE: <br /> ----- __- -- ___ _.___-._-__.----- APPLICATION FOR SANITATION PERMIT Permit No,.�.K7 <br /> ----------------- (Complete in Duplicate) Gf�� <br /> __ _____----___--_-__---._---_-_---._..-_._-.--- This Permit Expires 1 Year From Date Issued <br /> Date Issued ___.__ ___�.//___. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein dib d.� <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOTION_.__ I)- -----�.- <br /> _ _ eq, ! <br /> Owner's Name - ------- - Pone -_1_ .�.. <br /> Address------------------------------------T 1-.-1--------------- -d - 'S U© '--------------------------------------------------------_------.................. <br /> Contractor's Name-----------------4 5 ........ c---------------------_------------------------------------------------------- Phone................................... <br /> Installation will serve: Residence [K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ----L Number of bedrooms ---Z_Number of baths Lot size --------- ."(------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table 4.0 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam R, Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) NoPS-.New Construction: Yes ❑ No D4.—FHA/VA: Yes ❑ Noji� <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-----------------Distance from foundation_-----------------Material_-_-.--.__---______--.-_.-_.--_-_--_.-_-__-_.__-. <br /> ❑ No. of compartments--------------------------Size-------------------------------Liquid depth.-------------------------Capacity------ ---------------- <br /> Disposal Field: Distance from nearest well---- Distance from foundation--_-�S_°------Distance to nearest lot line_-__� _�_. <br /> Number of lines____________________L_____________Length of each line--------------- -------.Width of trench.--.___Zq-_-'_----__-___._.._ <br /> tc <br /> Type of filter material__5'_- _ _(L Depth of filter material--_ -.---Total length-----------------`_.1---------------- <br /> j <br /> Seepage Pit: Distance to nearest well------f4S__1__Distance fro foundation----SSS. .___.Distance to nearest lot line---_ -d------- <br /> . - <br /> [ Number of pits.-----t--------------Lining material_ -( Size: Diameter---33r..._.-___.Depth-------�..�_'------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation. _-----------------Lining material------------------------------------- a <br /> ❑ Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. 3 <br /> Privy: Distance from nearest well--------------------------------- ---------------Distance from nearest building__--_____-_-_._____--------------_-.-. <br /> ❑ Distance to nearest lot line------------------------------------------ ---------------------------------------------------- --------------------------- ---------------- r <br /> Remodeling and/or repairing (describe):----------------- ----------------------------------------------------------------------------------------------------------------------- ------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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) --- ---- --------_- ---- - ------------------- ----------------------------------(Ow r a /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 /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----------------------------------------------------------------CY- WI,C--- DATE----------- ��- ��1 - --...ate__.----------- <br /> REVIEWEDBY------------------------------------------------- -------- -----------------------------------------------------------...... DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------- --------- DATE------------------------------------------------------------ <br /> Alterations and/or recommendations------- ---------- - -------------- ---...------------------------------------------------------------------------------- ------------------------------ <br /> ------------- ------------------------------------------------------------ ----- ----------------------------------------------------------------------------------------- ---------------------- ----------------------­- <br /> --------------------------------------- <br /> ----------------------------------- ---------------------------- --------- ------ ------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------- --------------- ----------------------------------------------- ----------------------------------------------------------------------- ------------------------------------------------------------ <br /> -------------------------------- ----------------- ----------- ------------------------------- -------------------------------------------------- ---------------------------------------------------.--.-------- <br /> FINAL INSPECTION BY:.-.- --------------------- Date------`r ^Z �G ------- <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 /> F.P.CO. <br />