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FOR OFFICE USE. <br /> --------------- ------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. f <br /> --------- -------------- ---------- --------- (Complete in Duplicate) Date Issued <br /> --------------------------- --------- ------------- I This Permit Expires 1 Year From Date Issued ._....1.-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 _?ZJ_2 <br /> ----------------------- ------ ....................................................................................... <br /> Owner's Name--- ...... -- --- ------ ---------- Phone.................................... <br /> ....... .... <br /> --- ---- --- -------------------------------- <br /> Address...... . .. . ..... <br /> ............ <br /> Contractor's Name---- .. ............. <br /> C-' <br /> -------------------------------------------------------------------------------------- Phone................................... <br /> Installation will serve: Residence Of Apartment House [] Commercial [iR"T *1ra!2r Court E] Motel 0 Other ❑ <br /> - <br /> Number of living units: -_--t__ Number of bedrooms .-Z- Number of bathl-9,Lot size .................................. <br /> Water Supply: Public system a--community system El Private [] Depth TO Water Table .40- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam [3 Clay E] Adobe RrlHardpan I-] <br /> Previous Application Made: (If yes,date.-______.____..__-.) No PTNew Construction: Yes 0-INo E] FHA/VA: Yes Ej No e.— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> ................... <br /> Se nk: Distance from nearest well_,0t&0_14..Distance from founclation./ '­­­­­ <br /> A_ Material... Avv., .....�............. <br /> Septic <br /> No. of compartments----I----------_-------Size---- g------L i q u i d depth ..$1------------------Capacity...k-990 <br /> Disposal Field: Distance from nearest Distance from foundation./O..............Distance to nearest lot line.4_1 <br /> -------------- <br /> E11- Number of lines-------J_----------------------.-Length of each line.....9-0.0-------------------Width of trench___.- _--------------------- <br /> Type of filter mate riaCZp_C_��---------Depth of filter material.._., length........9-ple.......................... <br /> Seepage Pit: Distance to nearest well---—----------------Distance from foundation---/b....r-•-.....Distance to nearest lot line.6i.._...... <br /> &K- Number of pits.--.___I_____________Lining material___" ...Size: Diameter__-_- M&�........Depth------Zj>..................... <br /> Cesspool: Distance from nearest well.................Distance from foundation--_----------------Lining material..................................... <br /> 0 Size: Diameter--------------------------------------Depth-------------- -------------------------------------Liquid Capacity............................gals. <br /> Privy: Distance from nearest well_-__--__._-_--_______________________ _______Distance from nearest building___.__............_..._.._............_... <br /> F1Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (descri_be)____ .- ---------------------------- -------- .. ...... <br /> SAAR ..ol............. <br /> —--------..... <br /> -------I - 0 ­_ ---- - ------ ---------------------------------------------------------------------------------------- <br /> - -- - ----------- ---- ------- ----------- ------ <br /> 44F ----------- ----- ------ _­ <br /> ....................... ..................................................................................................................I............................................................................. <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:----------------------------------------- -------------------------__------------------------------------(rifle)------------------------------ ------------ ----------------- <br /> (Plo+ 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 <br /> ATE...REVIEWED BY----------_-------------........ -K�j---- <br /> ­------------------------------------------------------------------------------------------ DATE............................................................ <br /> BUILDING PERMIT ISSUED----------- -i- --- -•• DATE............................................................ <br /> - ------------ A <br /> ------------------------------------------------ 1?1... .............. <br /> Alter!fionii and/or recommendations:.... -..(p3------------- ....... ------...... <br /> ------------------------------------------ -----------------------------------------........................................................... ................................. <br /> ------------------------------------------------------------------------------------- ........................................................................................................................................ <br /> ..........................................------- ----•--------------•--------------------------------------- ----------------------------------------------------------------------------------- .......................... <br /> ------------------------ ------------ —------- ----------------------­---- ------------ ------------------------------------------------------------------------------..............-------------------------------------- <br /> FINAL INSPECTION BY:.------Ldp ----------------------------- 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 /> ES 9 REVISED 5-59 2M 5-62 ATLAS <br />