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FOR OFFICEU E: <br /> --:��----- --- ----���.��----- -- ----- Ill � + <br /> _____/-------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ...�.'�1.._:;7._ <br /> Cp ' --------- --------------------------- <br /> -- (Complete in Duplicate) (p ``� <br /> --------.--- This Permit Expires 1 Year From Date Issued Date Issued ...._./z _!._-./ <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 /> JOB ADDRESS AND LOCATION---------i•--••-a-5 =�'(od........................................................................... <br /> Owner's Name------------------- 1�!Y1�. .-------- ----------------------------------------------------------------- Phone.................................. <br /> Address----------------------------------S-And- <br /> Contractor's Name ............................. <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ..-L. Number of bedrooms ,,3--- Number of baths ---I... Lot size ........ �.�__taQ.1.................... <br /> Water Supply: Public system [g Community system ❑ Private ❑ Depth to Water Table .A;-ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, Hardpan ❑ <br /> Previous Application Made: (If yes,date___________________) NOA New Construction: Yes E] No pg. FHA/VA: Yes E] Nog <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted`if'public sewer is available within 200 feet.) <br /> Sep 4 9nk: Distance from nearest wellJ✓LrAA_.Distance from foundation-_.................Material._.._.....__________......__......._....___.__... <br /> No. of compartments---,.=---=----------------size------------------------------ ------Liquid depth...........--------_._--_Capacity..................... <br /> -- <br /> Disposal Field: Distance from nearest well_'._/__ ..Distance from foundation....................Distance to nearest lot line.................. <br /> Number of lines___________________________________Length of each line------------------------------Width of trench-----------__-,-__.-_-.________-__ <br /> 0 Type of filter material___________________-___-Depth of filter material..__-_______-___-__....Total length....................................... <br /> Seepage Pit: Distance to nearest well&—?- ____Distance from foundation.....................Distance to nearest lot line.. l <br /> t4 Number of pits_____________________Lining material-----------------------Size: Diameter---9-/xDepth.._ %7-`��!!/�.x.-_ <br /> Cesspool: Distance from nearest well-----------------Distance from'foundation-_.-______-_..___.Lining material..._...___..___...........__._._...... <br /> Size: Diameter--------•-----------------------------D� th--•-----.-----•-•--------- --••-gals. <br /> P ----------•--------------Liquid Capacity--•---•---._.....-•-- <br /> Privy: rr Distance from nearest well-------------------------------------------------Distance from nearest building----------- <br /> Distance to nearest lot line---------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):------- -----------------------------------------'-•-•-------------•------•--•-------•---------........................................................ <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, Statep1 (s,,Apd rules and egula ' of the San Joaquin Local Health District. <br /> --- - _--(Signed)------ --- �---- - -- --- �---------- ---"`----"`"---"-------------------------------------------------------------(Owner and/or Contractor) <br /> By:--------------------------------------------------------------------------------------------------------------------- --------------(Title)----------------------------------------- --- ---------------- <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 /> REVIEWED ----------------------------------------------------------------------------------------------- /v <br /> DATE............................................................ <br /> BUILDINGPERMIT ISSUED--------------------------------•----------------------------—------------------------------------• DATE............................................................. <br /> Alter tions and/or recommendations: -=----------------------------------•------------------------------- --------------------------------------------------------•--.- <br /> -- - - - - ------ --- --- <br /> -•------•------•----------------------- ----------------------------------------------•------------•---------•---------•----••--•------------------------------------------.----------•---•------•-- -----• <br /> .................................. <br /> FINAL INSPECTION BY: --- ----- - -------------------- Date----- ��I/ ------------------------------------------- <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 REVISED 9.59 F.F.CD.2M 6.60 <br />