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FOR OFFICE USE: �..�� �� / <br /> ------------1---------- -­---------- <br />------------------­­ --------------/.............. APPLICATION FOR SANITATION PERMIT Permit No. .. 1;Z_6 <br />--------------------------- ----------------------- (Complete in Duplicate) <br /> ----------------------------------I------------------- This Permit Expires 1 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 0 <br /> ,fdinance No. 5 <br /> JOB ADDRESS AND ATION---- ------- -----------­- ........................................................ <br /> Owner's Name............ ........ ----------------------------------------------------------- Phone.................................... <br /> .,_ <br /> Address....................... ......-$.--1'1_. ___ ,.. _��. . ........ -----------*----------------------------------------*-------­------------------------ <br /> ------------- <br /> Contractor's Name. <br /> ------------ ............................................. Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court El Motel 0 Other 0 <br /> / <br /> Number of living units: __-f Number of bedrooms Number of baths ./-- Lot size ..... ...,2...0.......................... <br /> Water Supply: Public system U Community system Ej Private El Depth To Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam E] Clay Loam E] Clay E] Adobe)Z Hardpan 0 <br /> Previous Application Made: (If yes,date---------_--------) No E] New Construction: Yes [I No� FHA/VA: Yes F] No El <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 141n"�---Distance from foundation--- --------MatFial----------------------------- ... ...... <br /> -N.. of compartments.-------- Size_//,�,"�_­­�/`­­Z_SE---...Liquid dep�th__4/ ----------Capacity._.Z. <br /> Disposal Field: Distance from nearest well_21Z?�_._Distance from foundation_�Q----------Distance to nearest lot line........... <br /> Number of lines.......y-----------lf�------I----Length of each line----//,'...................Width of trench..2-Z-------------------_- <br /> Z - / 00 <br /> ZQ............... <br /> Type of filter maferiaI.­.'_.,_A__'_ _��-----Depth of filter material 'f-----------Total length-----_--------------�/ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line..._.._.......... <br /> 1-1 Number of pits----------------------Lining material-----------------------Size: Diameter-_-.---__-.-----_...._-Depth_...._.._.._..................... <br /> Cesspool: Distance from nearest well----- ----------Distance from foundation--------------------Lining material........._........_.-__............._ <br /> 11 Size: Diameter-------------------------------------Depth---------------------------------_----------------Liquid Capacity---- •-•----------•..gals. <br /> Privy: Distance from nearest well_________________________________________ _______Distance from nearest building------------------------------------------ <br /> F1Distance to nearest lot line-------------------------------------------------------------7---------- -------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):_ __ ---------- <br /> ----------- -------- /......................... -4- <br /> ......................................................-------------------------------------------------------------------- ------------------------------ -------------------------------------------------------------- <br /> ----­--------------_------ .........................__------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------------__-_-_-•-__--.-___-_____-•--_____--_•-----_-•_--__--_____----__----•-••.-_.---_-_--___----.-_--__---__-______-............................................................... <br /> I hereb5i.fy that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, rate <br /> T laws, and rules and regulations of the San Joaquin Local Health District. <br /> .--(Owner and/or Contractor) <br /> ---------- ........ ------------------ ------ <br /> (Signed).... -- - -------- --------------- -----------------------7 <br /> By:......................................................... ...... -------- -----------------------------_-(Title, <br /> /-------------------------------- --------------- <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 /> BUILDING PERMIT ISSUED--------------------------------------------------------------....................................... DATE------------------------------------------.....-----........ <br /> Alterations and/or recommendations:............... ------------------------------- ............................................................................................................... <br /> ---------------------------------------------------------------- ------------------------------------------------------------------------------- <br /> Znt-63 <br /> -------------------------.......... -------------- <br /> ......................................2_�---- -kxs�, � ..... ---elf <br /> ------------------------------------------------------------ ---------------- ... ..... <br /> ... ..... .............. --------- --------------------------------------------------- <br /> FINAL INSPECTION BY---------------------------------------------------------------- Date-----------.r.------ 774Z,;_3...... ------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 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 2M 5-62 ATLAS <br />