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FOR OFFICE USE: (� <br />--------------------------------------------------------- � <br />_______.._.___.______._............._____-----__ APPLICATION FOR SANITATION PERMIT Permit No. ..../. ...��.�'. <br />------------------------------------------------------- (Complete in Duplicate) <br />---------------------------------- ---------------------- This Permit Expires 1 Year From Date Issued <br /> 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 /> JOB ADDRESS AND �"CATION ..... !'"�e 3 3......................................................71*----------- <br /> Owner's Name --'•-�_--- - --------- ------------------------------------------ --- -- hone.................................... <br /> Address..--------•- --•---•�--- l g E <br /> Contractors Name. ............ Phone......................... <br /> Installation will serve: Residence K Apa ment House ❑ Commercial ❑ Trailei Court ❑ Motel,❑ Other ❑ <br /> Number of living units: ---1_ Number of bedrooms __ Number of baths ---/---5-at size -----------� ......... <br /> Water Supply: Public system ❑ Community system ❑ Private IN Depth To Water Table/.Q. 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____________________) No in New Construction: FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic?���N <br /> nce from nearest well_________________Distance from foundation__-_-__--__..__-___.Material....._......_....._......................_....... <br /> ❑ of compartments--------------dd---------Size-------------------------------Liquid deP.t�--------------------Capacity...................---- <br /> Disposal Field: Distance from nearest well..... Distance from foundat,i.oJL._.__ .`r .�.D,�i Lance to nearest lot Ii e.. <br /> Number of lines.__.__. Length of each line) , 0'_n�...:►VNidth of trench.___.._ <br /> 9 -- -- �------------•----•-•-- <br /> Type of filter material3�_._____,...:--Depth of filter material..,.Zf ....Total length------1 '_`�-�--_V....................... <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line._._._._.._..._.. <br /> 11 Number of pits----------------------Lining material-----------------------Size: Diameter.......................Depth__--__---.-_____-.--••-••--__--_- <br /> Cesspool: Distance from nearest well_________________Distance from foundation._-._________--___.Lining material........_............................ <br /> p Size: Diameter--------------------------------------Depth_----- -------------------------------------------Liquid Capacity............................gals. <br /> Privy: Distance from nearest well-----------------------------------------_-----.-Distance from nearest building------------------------------------------ <br /> F1 <br /> ___--__------ _,_----------.--._____---❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------•----........................ W <br /> Remodeling and/or repairing (describe):-------- -----••--------------------------------------------•---------------•---------•----•----........................................................ <br /> --•--...--•---•------------------•-•-----------------•--•-----------•------------------------•••----•-----•---•----......I........................ -•-------------------•-------..-•-•--•-•----•-.._....._............. <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 /> (Signed)............... --------------- ---------------/-�-------(Owner and/or Contractor) <br /> By:.........................................................................--------------------------------------•-------------------(Title)..-•----1.0'-----o ---- ---- --------- <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 BY---------------------------------------------------------------------- -------- - -- 6;� <br /> DATE---.-------------------------- <br /> BUILDINGPERMIT ISSUED---------------------_------------------------ ------------------------------------------------- DATE...........................................------------------ <br /> Alterations and/or recommendations----------------------- -----------------------------------------------------------------------•-------•------------------------------------•----••----•-- <br /> ---•--------------------------------------------------------------------------------- ------------------------------------------------------------------------•--------------------------------------------------------------- <br /> -------•----••---••••------------------------------------------------------ -----------_----- ---------------•-----------------•------•-•••-••----•-••••---•-•-•--••-------------•----•---••-•--•-------------•--•-•----•- <br /> --------------------------------------- ------------------------------------------------ ---------------------------------------- -----•••--•---•--..........•-•----•••--•---••-------------------•-•• ----------------- <br /> FINAL INSPECTION B Date --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Strut <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED a-59 2M 5-62 ATLAS <br />