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KOFFI� US <br /> --------------- <br /> ----------------- -------------- ---------------- APPLICATION FOR SANITATION PERMIT Permit No. _...A...1�. <br /> --------------------------------------------------------- (Complete in Duplicate) L� Z <br /> ------------ --- 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 /Couunty Ordinance No. 549. <br /> JOB ADDRESS AND LOC TIO ....__. <br /> Owner's Name._._.-_ = r ------• ...... Phone.................................... <br /> ------- <br /> Address......... - <br /> - <br /> Contractor's Name.---------. -- ------------------••----------------------•--------------•----••-----------•---------. Phone.................................- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units- ._l Number of bedrooms <br /> __-- Number of baths -/--. Lot sizef�ld.--•-•-------------------------•- <br /> Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table - 1 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay ❑ Adobe lardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No FT"'New Construction: Yes ❑ No 2—FHA/VA: Yes [T,-"No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Spptic Tank J Distance from nearest well---------------_Distance from foundation------..............Material-------.---_----__-_...-.__.............-........ <br /> GEYZI1 No. of compartments--------------------------Size-----------------------------...Liquid depth---------- ------Capacity-- <br /> Disposal Field: Distance from"nearest well-----------------Distance from foundation--------------------Distance to nearest lot line................. <br /> � flI- Number of lines-----------------------------------Length of each line---------------------------...Width of french------------------------------------ <br /> Type of filter material----------------------_.Depth of filter material-------_--_.__----...Total length---------------------......--------------- <br /> Seepage <br /> -_-_----..-_.-See a e'Pit: Distance to nearest well.------------- ----__Distance f m foundation_-_-r <br /> r0�.....Distance to nearest lot lin-e--.-.- <br /> ,2 <br /> _.... <br /> Number of pits------1------------Lining material- � Size: DiameterS_- --------Depth_-�4- --•--•----_-•- <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 /> ----------------------------_-.. <br /> ❑ Distance to nearest lot line------------- ---------------- <br /> _0--------------------------------------------------------_-----------------I—............. <br /> -----•----•-------•---••---•----------------------- <br /> Remodeling and/or repairing (describe):---------------------------- <br /> --.......-•---••--•---•--•-------•--•--- -----------•-•-------•-----•-- •- <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,aandrulls and regulations of the San Joaquin Local Health District. <br /> (Signed} <br /> ---- ----------------( ' Contractor) <br /> By:--------•----•-•------------------------------------------------------ -- - ---- 4;•ag-------------(Title)-- <br /> (Plot plan, showing size of lot, location of system ' elation to wells, buildings, etc., can be laced on reverse side). <br /> FO EPAR MENT USE ONLY <br /> APPLICATION ACCEPTED BY-C_..: C. f ------L. ------------------•--------- DATE-------- <br /> REVIEWEDBY----------------­----------- �f------ ------------------------------- ................................................ DATE----- -•.....------------------- <br /> --------------------------- <br /> BUILDING PERMIT ISSUED.......Z -- <br /> --•--•-------------------------------------------- -------------------------------------. DATE.---- <br /> Alterations and/or recommenda.tions:_------------------------------------------------------- <br /> ---------------- <br /> -------------------------------- ----- <br /> -- - -------------------•---------------•-------------------•-------------- --------•----------••----------- <br /> FINAL INSPECTION BY:__�:- G -^-- Date------------------- 4_-_- =z._.-_.... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Sirnt 205 West 9Th Street <br /> Stockton,California Lod],California Manteca,California Tracy,California <br /> th 0 hEVISED S-S9 Zft 5-61 ATLAS - <br />