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FOR OFF)CE USE: <br /> 0 IV <br /> ------------- --��APPLICATION FOR SANITATION PERMIT Permit No. <br /> --------------------------------------------------------- (Complete in Duplicate) <br /> A <br /> ko L. <br /> ................................... . ."�� This Permit Expires I Year From Date Issued Date Issued ........_.. . <br /> � <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 /> 0 <br /> JOB ADDRESS AND LOCATIO ---- -- ......... el'?o <br /> .................................................................. <br /> Owner's Name........... <br /> .................. ... ... . ........... ..........................- Phone.................................... <br /> Address.................................... ---------- -- --------- ------•------ ----------- ............... <br /> Contractor's Name----------------------•• . ... ..... -- -- --------- ------------------------------------------------------------- Phone................................... <br /> Installation will serve: Residence partment House [:] Commercial E] Trailer Court [] Motel 0 Other 0 <br /> Number of living units: Number of bedrooms .._9. Number of baths f_.... Lot size `�4......mv............................ <br /> Water Supply: Public system eCommunity system El Private E] Depth to Water Table .&Wft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam E] Clay Loam E] Clay E] Adobe @90'Vardpan <br /> C1 <br /> Previous Application Made: (If yes,date_________________.) No R?-'-New Construction: Yes D No 2---FHA/VA: Yes F] No Ser., <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within,100 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....... .........bistiance from fou;dati6n.....................Distance to nearest lot line.........._...... <br /> El Number of lines-----------------------------------Length of each line...............................Width of trench..............._..__...._._.,__.... <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length-----------_--_--------................ <br /> Seepage, Distance to nearest well--------------------2--Distance from bqfounclationZ.-I /........Distance to nearest lot line...3-- /_... <br /> 7--------�� Number of pits--------/--- <br /> - --------Lining material__ Size: Diameter---32�K_11-------Depth-_;:2.0.................. <br /> Cesspool: Distance from nearest well----_-------_-Distance from foundation--------------------Lining material...................................... <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity------------...............gals. <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building.......................................... <br /> ❑ Distance to nearest lot line------------ <br /> fff jqq ////J J�///y i <br /> .................................. <br /> Remodeling and/or repairing (describe):---------------------- <br /> -------------------------------------------------------------------------------------------------.............................................7------------------------------------------------------ --------------------- <br /> ............----­-­---...............................T........................................................... <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, a r les and repraDins the San in Local Health District. <br /> (Signed)--------------------- -- ------------ -- - --- -- ---- . ... .. ... -----------------_------_--------------------_- Owner and/or Contractor) <br /> By:. --------------------------- -- -✓- -- -­------­-------(Title).......e�4-------- -- <br /> .ve- - - - ----- --- -------------- <br /> (Plot plan, showing size of lot, tion system in relation to wells, gs, etc., can be placed on reverse side). <br /> y FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- -��a------------------------------------------------------------------ <br /> REVIEWEDBY----------------------------------------- -------------------------------------------------------------------------------- DATE................................................... <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------....................................... DATE............................................................. <br /> Alterations and/or recommend tions:.------. ----------------------------- - ---- .......... ... ... .......................... ........................................... <br /> ---- ---- .... ..................... . .......................................... <br /> ----------­-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------............. <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.................................. <br /> ..............-------­-­--- ...... ------------------------------- -­-----------­---­---I----------------------------------------------------------- .......................................... <br /> ---- ---------------------------------------------------------- <br /> FINAL INSPECTION BY:------9...Dr- ---- -------­------------------ Date------- <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 /> EM-9 REVINED 8.59 r.P.CO.2M 6-60 <br />