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APPLICATION FOR SANITATION PERMIT Permit No. <br /> ----------------------------------- -------C°------------ (Complete in Duplicate) Date Issued __:�115�1?4164­ <br /> -------------------- ---------------------- --------- This Permit Expires I 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 /> .1) <br /> JOB ADDRESS AN LOCATION-.-.,-,A--0--2-------3--------4_ ............................................................................. <br /> . ..... ---—----- ....... <br /> Owners Name- --------- ........ ........... ------ --------------------------------------------------------------j----- Phone--------_------------------ <br /> Address... ..................... .................................................... ------------------------..................................... <br /> Contractor's Name------ .............. <br /> ...............--------------------------------------------------------------------------------------------------- Phone................................... <br /> Installation will serve: Residence [�]—A_partment House E] Commercial C] Trailer Court [] Motel E] Other [] <br /> Number of living units: .--1___ Number of bedrooms .3.. Number of baths __/--- Lot size ------------------------ <br /> Water Supply: Public system [B--Community system E] Private ❑ Depth to Water Table 4- ft. <br /> Character'of soil to a depth of 3 feet: Sand [-] Gravel E] Sandy Loam El Clay Loam El Clay 11 Adobe�iardpan El <br /> Previous Application Made: (if yes,date--------------------) No ID, New Construction: Yes fa-"No E] FHA/VA: Yes 0 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---—-----Distance from founclation-Y;7.4----------Material---712X`e� <br /> ------------------------------------------- <br /> 1!r No. of compartments---�---- -------Size-----3-_X -9------Liquid depth_____ ..__-..__.Capacity..... <br /> Disposal Field: Distance from nearest well_...-_..._Distance from foundationZ.0...(----------Distance to nearest lot line._._.__.--.4L <br /> Number of lines____ _._,.--_.-__. Length of each line-----7S5—_______________Width of french------ --------------------- <br /> Type of filter material..... C_ ------Depth of filter material---48-----------------Total length....1%1-'-A----­-------------­----- <br /> Seepage Pit: Distance to nearest well- —_____________Distance from founclation_2e!!�............Distance to nearest lot line---0-—__ V <br /> ­ 0 <br /> Er Number of pits-----15�--------------Lining ---_.Size: Diameter--3-?--------------Depth....... "'__-_.._-.___- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__-__ _---._----------------------- <br /> El Size: Diameter--------------------------------------Depth-------------------------------------- --------Liquid Capacity----------------------------gals. <br /> %A <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildin❑ g------------------------------------------ <br /> Distanceto nearest lot line---------------------------------------------------------------------------------------------------------------------------------_---------- <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 /> 1001 / <br /> (Signed)--------------- -- ------- I- ----------- ------------------------ ---------------------------------------------------------- -----------------------------(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 /> 4 <br /> APPLICATION ACCEPTED BY..";�_ a----A4_lct---------------------------------------------------------------- DATE--- X----------------------------- <br /> REVIEWEDBY-------------------------------------------------------------------------------_------------------------------------------ DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> Iterations <br /> .4 and/or recommendations----------------------- ------------ --- <br /> --------- <br /> __11 ------------------.v- 0--.-..--.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-..-.-.-.-.-.-.-.-.-..--.-.-.-.-.-.-.-.-.-.-..................-.-.-.-.-.-.-...-.-.-.--.-..-.-;.i.�.7... <br /> ...................... <br /> --­---------- <br /> ......... .............. .......=........................... <br /> ------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------­--------------------------------------------------------------------------------------------------­­---------------------------------------- --------------------------------------- <br /> FINAL INSPECTION BY:------ -----_------------------ Date......� --------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Naulton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 3M 3-'63 F.P.00. <br />