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�010E USE:----- �� ° <br /> JJ <br />________________.-__.._._________._ ------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ..1---- <br /> (Complete in Duplicate) f� / <br /> This Permit Expires 3 Year From Date Issued Date Issued _....:1 l - <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.---.-/,Q/--0�' rte..... <br /> q 6 <br /> Owner's Name.-._. .. ------ --�.---- ....-----... Phone <•.3 <br /> Address------------------- -- -----`----•--•-------------•------•---•---------- ----------------------------------------------------------------- <br /> Contractor's Name--------------- -------------------------------------------------------------- . Phone................................... <br /> Installation will serve: Re dance (& Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms _-3-- Number of baths `.rLot size ..._-- �------ -_.f -rte 11'�............. <br /> Water Supply: Public system ❑ Community system ❑ Private §�. Depth to Water Table -------- 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 ❑ New Construction: Yes C& No ❑ 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 /> Septit mak: Distance from nearest well____eA.__.Distance rom foundation_-/ __-----_-..Material--_/?----------------------------------------- <br /> No. <br /> ----_------- ----------- --------------- <br /> No. of compartments-------1��-------------Size... Liquid depth------- --------------Capacity...zaa. ---- <br /> Disposal d: Distance from nearest well.-SO------Distance from foundation_-_-Y-U.......Distance to nearest lot line----- <br /> Number of lines...............P---- _---.-Length of each line____.---._-g_D._/-_-..Width of french------2.....-.I--.....--.... <br /> Type of filter material. .,--.Depth of filter material--.-- -------Total length---------- - -------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line............ d <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter.......................Dept h--------------------------------- G <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material..................................... <br /> ❑ Size: Diameter--- ------ --------------------------Depth-------------------•-------------------------------Liquid Capacity-------...••...............gals, <br /> Privy: Distance from nearest well----------------------------------------- ------Distance from nearest building---_----_---_--___---______-_--_-.-----.-. <br /> ❑ Distance to nearest lot line-----------------------------------------------------------------------.---------------------------------------------------------------------- 17 <br /> Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- (a. <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 /> .. <br /> gy -- ------------ {T'itle} <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-------------------------- �` - <br /> DATE -0 --------------- <br /> REVIEWEDBY--------------_------_- •-•---- -----------------•-----•-----------•------------------ ......... DATE-------- ---------------------------------------------- <br /> OUILDING PERMIT ISSUED........................................---------------------—...........•-.---..................... DATE--------.-...-----••-------------------•-•-- <br /> Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------- ---------------------------------------------------------...---------------------------.._-------=--•.............................................. <br /> -•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------• <br /> FINALINSPECTION BY:...---- V6--------------------•-•--------•------. Date--- --------------------- ---------............ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 1241vamaro Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> r� <br /> 9% 9 REVISED 13-a9 21A 6-61 ATLAS <br />