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APPLICATION FOR SANITATION PERMIT Permit No. .,l/. ............ <br /> (Complete in Duplicate) Date Issued 14 <br /> This.Permit Expires ] Year From Date Issued <br /> Application is hereby made to the San JoaquinLocal Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No.v549. <br /> JOS ADDRESS AND LOCATION -------------------------------------------------------------------------------- <br /> �= <br /> Owner's Name_... F Phone. <br /> =... --•--------------------------------•------------------- <br /> iAddress ------ --•-_... � S -------------------- -------- -- -------------- <br /> Phone <br /> -----------•- <br /> ...Phone-•-•--------------------•-------'Contractor's Name <br /> - <br /> Installation will serve: Residence <br /> Apartment,House ❑ Commercial E] Trailer Court ElMot C] Other El <br /> 4 Number of living units -- Number of 6e'�d,rooms -A._:Niimber of baths __/__ Lot size .yl_.X___ �------------•------.- <br /> .• <br /> Water Supply: Public system �mmunity system [3 Private ❑ Depth to Water Table eft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Ej Gravel' ^ andy Loam ❑ Clay Loam El Clay E] Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ -No FHA/VA: Yes ❑ No Wj--- s <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> 7 Se Tank,> Distance from nearest well------------- --Distance from foundation-------------------Material-------------------------------------------------- <br /> r14 ------- <br /> _-____.__--.._-----._-----_--"_.----_-_-_---_. <br /> rl f No. of compartments--------------------------Size---••----......-------- ,� Liquid depth------------------------- Capacity <br /> Disposal Field: Distance from .nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--------------_ <br /> I p 7?4f Number of lines--------------- f"--------------Length of each line--------.--------------------.Width of trench.----------------------------------- <br /> Type of filter material-__-M---- ------------Depth of filter material or <br /> length--- <br /> Seepage Distance to nearest well-____--------Distance fr m foundation_-__ . ., _.. ista ce to nearest lot line----- -- <br /> Number of pits-.-.--/---"----_.Lining material__fl �l� r-Size: Diameter----__-,, '�`_____Depth----...�_v `--- -----Vol • A/ <br /> Cesspool: Distance from nearest well-__.__----.--.__Distance from foundation--------------------Lining material---_.-_-.-_--_-____----.---_----.-.-. <br /> ❑ Size: Diameter------------------ -------------------Depth----------------------------- ------------------------Liquid Capacity---------------------- ----gals. <br /> Privy: Distance from nearest well--------------"-___a,_--_------------------ ,-_Distance from nearest building---------------------- <br /> ❑ Distance to nearest lot line --------------------------- -------------------------------------------------------------------- (� <br /> Remodelin and/or repairing (describe):---------- E ---------•--------------------------------------------•------------• V� <br /> g 4 <br /> r --------------------------------------------------------- ----- <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 rul and regulations of the San Joaquin Local Health District. <br /> (Signed) -� i `----- ( ad�r Contractorl <br /> By:---------------------------------------------..------------- ---- (Title) -, <br /> } [Plot plan, showing size of lot, location of sys in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY__ 0------------------------------------------------•------------------•---- DATE------- ------•---------------- <br /> REVIEWEDBY--------------------------------------------- --=---------------------------- ------------------------_-- ------------------ DATE------------------------------------------------------------ <br /> IBUILDING PERMIT ISSUED---------- ---=-------------`-----------------------"-------------------------------•--•------------ DATE------------------------------------------------------------ <br /> Alterationsand/or recommendatioris---------------------------------------------------------------------------------------------•-------------- --••-- ----------_---------....---------- <br /> --------------------- --------------------"----------------- ------------------------------------------------------------------------------ <br /> ----------------------------------- -----------------•-------------------------------------------------•-----------••------------------------------------------•-----------------­­------------------------------ <br /> 3 ------------------------ <br /> ---------------------------------------- <br /> 1 <br /> FINAL INSPECTION BY:-----.- ------- ---- - Date---------- 0---------------------------------------- <br /> . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.M 130 South American Street 30(TWest-Oak Strew132 SycamorCStree+ 814 North "C" Street <br /> Stockton, California'. lodi,`'CaliForniau '` Manteca, California Tracy, California <br /> ES=9-2M Revised 6-;59 Co. <br />