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-FO,P`OFFICE SE <br /> r ^ . <br /> ---- -----3i j <br />-._------- -------------_ �: - ___--_--- APPLICATION FOR SANITATION PERMIT Permit No. <br /> -W_lr-------------- (Complete in Duplicate) 3 <br /> '""' Date Issued <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. <br /> - <br /> �� � ' <br /> JOB ADDRESS AND�10 --------- -------------•------•----------•--...--------------------------------- <br /> Owner's Name----• •-_ `� -- Phone__.............. ...... .... <br /> Address-- ._. ----- <br /> Contractor's Name-------•------•- f� -------------------------------------------------------------------------•---- Phone................---•••••......--- <br /> Instaliation will serve: Residence 94"*"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> `Number of living units. J_..___ Number of bedrooms { <br /> Number of baths <br /> Water Supply: Public system Community system Ug"'Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Z' mardpan ❑ <br /> Previous Application Made: {If yes,date--------------------) No I�New Construction: Yes Ea"No ❑ FHA/VA: Yes ® o ❑ CN <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> �No septic tank or cesspool permitted if public sewer is available within 200 feet.) l <br /> Septic T nk: Distance from nearest well ___ ______Distance from oundation----� .______.Material______ _� . �� .. <br /> /� r <br /> eta �1� __ .���L. �r <br /> No. of cam , rtments____ _---_---_.__-_Siz squid depth______ ________ ________Ca aci l <br /> Disposal ield: Distance from nearest ell._.- '.___._Distancrte.from foundation.:. ._ _. <br /> p . _ _ ,��✓::..___.Distance.to nearest lot line._._:.... <br /> I Ego"' Num6sr"of'linas.`�= = �: =--- _Lengthlof,.eac"k line_�� I <br /> = . Width of trench-- <br /> . - o; <br /> Type of filter material./ --QDepth of filter-,material-.._. ________.Total length__-_._ 4.h__ __________________ <br /> s' Seepage Pit: Distance to nearest ell____.r"�"_------Distance from fo ndation____�[r�_._..Distance to nearest lot line__e�'r. _�..- <br /> ®� Number of pits______________.Lining material__,/�fti.��--Size: Diameter-,.;� ----_____.,Depth_ _________________ <br /> Cesspool: Distance from nearest well_________________Distance from found_ation___._y--------------Lining material..................................... <br /> 4 - <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 /> ------------------•------•--------------------------------•----------•-••----------...._.--------------...----•-------•-------•----------•--------------•-------------•------•-------------------------------------------- <br /> I hereby certify that I have prepared this application ar�id.that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules andregu tions of the Sa Joaquin Local Health District. <br /> (Signed) f 3-- ---- -----.----- ----------(�, r Contractor) <br /> 6 !ice.,PJ----(Title). <br /> 1 <br /> (Plot plan, showing size of lot, location of system in relatio wells, buildings, etc.,-can'be.'placed on reverse side). <br /> FOR•DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ ___C�r ._ ..__ <br /> -- - ------------------ ---­--- -----•-•----------- DATE-.�.:-?-- ••-�`---- -�--------------------- <br /> -,-- REVIEWED BY .-------------------------------------------------- ----- DATE-------------- <br /> BUILDING PERMIT ISSUEDf_ ---------------------- --------- <br /> -------------------------------------------• DATE' '" -- <br /> Alterations and/or recommendatlons:___� --c----(,,�-- -------_ - ,tet. �s --- =----...-.-• •-----... <br /> --------------------------•-----------•- ----------•------------------------------------------------ ------------- -----------------------------------------------------------------------------------------••-------- <br /> •- -----------------------------------------------------------.-- --------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------`---------------... ----- �r <br /> FINAL INSPECTION BY:. __-- - ---------- - Date--- � -- -•_- ( ---- - -- -------------- <br /> QUIN CAL HEALTH DISTRICT <br /> 130 South American Str*et 300 West Oak Street 124 Sycamore Street 205 Weil 9th Street k <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 8M 5-61 ATLAS <br />