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FOROFFICE SP. � _.. �✓ '_ -- ----------------- ___________________ APPLICATION FOR SANITATION PERMIT Permit No. --------------- - •------------- ------ (Complete in Duplicate) ----- This Permit €x ires 1 Year From Date Issued Date Issued _ ..`.�.U__ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance-with County Ordinance No. S49. 7 `7°Fo " -c J08 ADDRESS AND LOCATI N__ - ------- __ - _________ ______ -___ ti 077— t f�j—J9- ------------------------- --- ----------------------- ---------•-- ----...----•------•----------------- Owner's Name ti �. ..: !-._.. = ----------------------------------------- ----- Phone-------------------- Address-`-------- co I "�' --••----------------------- •-----•--------------------------------------• ........................................... Contractor's Name......__ r ---•-••-------- -•--•------•---•---•-••-----•-•--------•....................... Pone._...........------...-----------.. Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ®� Number of living units: -------- Number of bedrooms -------- Number of baths ________ Lot size _____________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe EJ-1 ardpen ❑ Previous Application Made: (If yes,date--------------------) No [KNew Construction: Yes U2-No ❑ FHA/VA: Yes ❑ No C�— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiffed if public sewer is available within 200 feet.) Sept' Tar}k: Distance from nearest well_________________Distance from foundation--------------------Material _____-...________-_-.__...............•..__._.... pp•�j((�1�1r I No. of compartments--------------------------Size--------------------------------Liquid de th-.------------------•-----Capacity Disp al_F' Id,: Distance from nearest well-_______________Distance from foundation:...................Distance to nearest lot line---------.... ._ Number of lines-----------------------------------Length of each line.....----------------------.--Width of trench---------------------------------..-- t Type of filter material.......•-----------------Depth of filter material-----------------------Total length------------------------------------------ See -.----------------------- _-___-----•- 'V Seeps Pit: Distance to nearestll---7�__•------___Distance korn ,]� undation_.-7.�r-------Distance to nearest lot line_. P_.... ^h Number of pits..._.____..----------Lining materia l-___J�,tr�------Size: Diameter__._.-___._ .�T ------.Depth------1 -- ------------- -' Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material__.._-..___-___--__-_____-......____ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---•-•-------_-----•-•----gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---_______-_-_______-------- El Distance to nearest lot line.---------------------------------------------------_--------------- Remodeling and/or repairing (describe):__._aA_. i___,0 ---__-_--� -- .......................----------- ----••----•-•----------------------••------------••-•-----•---•----•----- ------------.----•---•----------•---•----------•-•---•-------•---------------•-----• ....------------------------------- ---------------•---------------------- -•-•----------------- ------•-----••--------•--------------------•---------- I ----------------------------- ... •--------------------------••---- --•--•`..._.. -----------------------------------------------------------------------------------------------------------------------------------_--------------------- --- I hereby certify that I have prepare hi application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and I ons of the San Joaquin Local Health District. i (Sign --••---•-•------•---------•--------• ..... F -- . --- --- ed) (Owner and/or Contractor) By: --------------------.....----- ------------------- -----------------------------(Title)------- •------------------•---------------- - --------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY \ APPLICATION ACCEPTED BY------- ` ---------------------------------------------------------------- DATE...... __-_r.h REVIEWEDBY----------------------------------------------------------------- ---------------------------------------------------------- DATE. BUILDINGPERMIT ISSUED-------------------------------------------------------•---------.---------- ---.------------------- DATE. erations and/or recommendations:_�------------------------------------------- ----------------------------------------•------._.-....-•---------------------------••-------------- ----•-----------•------------...---------.---•---------•--...---------------------------•-------------•-•--•----•--- -------•-•---------------------------•-----------------.----i-----•----------------------------------------------------------- -----------•--•---- 1 r FINAL INSPECTION BY:. C` �`7---------------------•------ Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street- 300 West Oak Street 124 Sycamort Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B•59 2M d-61 ATLAS