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FOR OFFICE SE:f <br /> Permit No. <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------- ---- / <br />------------------------------------------------------- (Complete in Duplicate) Date Issued -------------- <br />--------------------------------- --------------------- <br /> ---.yl-----------------------_...--_--_.._______..__.-__.._._ This Permit Expires 1 Year From 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 County Ordinan? No. 549. <br /> JOBADDRESS A ON ---------- -----------------------------------------•-•-••--•--------------...----••-•----------... -_------------ <br /> -• � -�Owner's Name---'--.., - - ,------ ......-.------•-------------------------------------------------------------------------------- Phone.......------------------------ <br /> Address---_-•-------•-------•-••• ---- --------- ------------------------------------------------------•----------------------•--•--•---------------------_--------------.._--------------- ------- <br /> Contractor's Name 'S T,� ---•--•---- Phone.................... - <br /> • -•------------------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: .-I-___ Number of bedrooms -----T Number of baths J.__ Lot size ___ _.xC_? ............................. <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[1—Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No [� New Construction: Yes ff"'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 /> Sep ' T nl, j Distance from nearest well---------------- Distance from foundation----__-------------.Material________--________..__....._------.--- <br /> -----------Liquid depth-- ------Capacity------------- <br /> No. of compartments--------------------------Size.-------•-.•---___-- ....---•-- <br /> Disp I Fielc�l Distance from nearest well------.--___Distance from foundation..-��--'______.Distance to nearest lot line _ ....... <br /> Number of lines_______I_________________________Length of each line___��_�_--_________...Width of trench.____�r�__ __...._____._.. <br /> Type of filter material.... t <br /> c-,_&_-Depth of filter material-------/$'_ .....Total length-------3_P............................. <br /> Seepage Pit: Distance to nearest well_.___—_----_______Distance,� foundation__i4�_(---------.Distance to nearest lot line-,4______--__•- <br /> Number of pits........1------------Lining material_____�l-k�-(�.1{�----Size: Diameter------ ..................... <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material----------------------------------- <br /> ElSize: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. .. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building---------------.________-.-_______-_-----. i <br /> ❑ Distance to nearest lot line--------------------------------------------- -•------------_--• ----------------••---•------------------•-------------•-------------- i <br /> Remodeling and/or repairing (describe):---------------- ----------------- ----------------------------...--------------------•----•----------------------•-------- <br /> --•---•---•--------------------------•-------------------•-----------.----------•------------------------•----------------------•--------------------••--• ---------------------- -------------------------•------------- <br /> --------------------------•-•----------------•------------------ " <br /> ------------•-•---------------------------------------------•---------------------- •--• -•-------------•--------------------------------------------- ---....------------------._....----------------- <br /> I hereby certify that I have prepared this appliFation and that the work will be done in accordance with San Joaquin County i <br /> ordinances, State laws, and rules and regulati s he San Joaquin Local Health District. <br /> (Signed) - -- ----- ------------------------------------------ -------------------------------(Owner and/or Contractor) <br /> By: ------------- <br /> -------------------- - ---- ------------------ lr,+lel <br /> (Plot plan, showing size of lot, location of sys m in I. lation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- .----------- - --------- ------------- DATE------------------- <br /> ............... <br /> BY----------------------------- ------- - ---- - -----------•---------_------------ DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED-----------------------_--- •--------------- DATE------------------...__......................... <br /> •----------- <br /> Alterations and/or recommendations--------------- ' ---------- <br /> _._.... = <br /> 7:31--) <br /> --•----------------------------------------------------------- - ---------------------------------------------------------------------------• ----------------------------------._...._. <br /> Date---42----- .._ _. .. ---------­------- <br /> FINAL INSPECTION BY:.____._(�-=-------- -------- -- - �-�`=-�-�_ ---------• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,Californla Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 2M 5-62 ATLAS S <br />