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FOR OFFICE USE: <br /> --------------___ _________________________________ APPLICATION FOR SANITATION PERMIT Permit No. ../ <br /> --------------------------------------------------------- (Complete in Duplicate} <br /> ------------------------------------------------------ -- This Permit Expires I Year From Date Issued Date Issued _ _-�.#._ . <br /> Application is hereby made to the San WHealth District for a permit to construct and install the work herein described. <br /> This application is made in compliance No. 549. <br /> JOB ADDRESS AND LOCATION ,� " ''` ----•--"-----------Name -r. - --------------------------------------------- Phone./... <br /> Address.-----•----•--------------------------•1. j7 �"Y,l_ . .... <br /> Contractor's Name ---- ------ ------------------------------------------------ Phone................................... <br /> Installation will serve: Residence ® Apartment House Comrnercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _,l___ Number of bedrooms ___.?� Number of baths __!__ Lot size ...__._..- /�c+. .a......_ <br /> Water Supply: Public system ❑ Community system [] Private W Depth To Water Table x_e ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 2 Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No JO New Construction: Yes L;� No [3 FHA/VA: Yes ❑ NoZ] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well..-..1"'_o-..Distance from foundation------/.a----_Material--------- . ____ ___________ <br /> 19 No. of compartments_____ ?1------Size....... ', �'_,i _.Liquid depth__-_-_,°r�----...__�.___Capacity__..____...t, .4.00. <br /> Disposal Field: Distance from nearest well___`` --Distance from foundation..___3__C-__.._-Distance,to nearest lot line___-3.5-._- <br /> ® Number of lines_---------_ l.____._______Length of each line____________._ 'v------Width of trench---------------"Y___________ <br /> Type of filter material._. ___Depth of filter material____,��---"----Tota l� length--------------- --- ..`......._.__ \ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---------------_ N <br /> ElNumber of pits----------------------Lining material----------.------------Size: Diameter--=----------.-------.Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------_'__._Lining material----------------._.-......__._-_.____ <br /> ❑ Size: Diameter--------------------------------------Dept h.------------ --------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-----------------------------------.----- -------Distance from nearest building---------.----------._._.______________._. \ <br /> ❑ Distance to nearest lot line_______________________ " "' (U <br /> Remodelingand/or repairing (describe);---------------------------------------------------------------------------------------------------------------•-----------------------•--•............ <br /> -----•-•--•-----•-------•------------------------------------------------------------------------------•----•---------•-•-------------•-----------------------------------------------•• ---------•---••- -------------- <br /> 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)---, la—.-�--- -------- --1------------------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By: r•---------------------•-•----------(Tit e)---------... <br /> (Plat plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -- --------------------- <br /> .U/&4-5-7-------------------------------------------------- <br /> REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE-------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> Alterationsand/or recommendations:------------------------------------------------------------..........................................-------------------------------------------------------- <br /> ----------------•--•-------••-•-----------------........---------------------------------------- -------- --------------------------------------------------------•--------------------------- ------------. ------------.... <br /> - <br /> -----------------­:------------------- -----------------------------------------------------------------------------------------------------------------•------.--•------------•--------- •--------------------------- <br /> ----------•---------•----------------------- ------------------- --------------------------------------------------------------------•-- ----- •-- ----------------------•--------------------------------------- <br /> FINAL INSPECTION BY:---- ___.._.. Date------ ..``r d __��. _..` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Wed 9th street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 13-59 2M 5-62 ATLAS tip• <br />