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FOR OFFICE USE: <br />------------ --"- ------------------------------ <br /> ------------:-------------- <br /> ----------------•------------------------------- -- ---------------------•--. APPLICATION FOR SANITATION PERMIT Permit No. ..1..,��.....:.- . <br /> ---- --- ---- ----- (Complete in Duplicate) ?/Z--- ----- This Permit Expires 1 Year From Date Issued Date Issued ... ........_ ?_-7� <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 /> .708 ADDRESS AND LOCAT N-------------- <br /> ------------ <br /> Owner's Name............... 7 .71a....M---•AM-D.-•----------- �...._.. oj <br /> Phone._..._. 3 / 3� <br /> Address------------•-----------------5A-.Igq.e.....................................--.._...-----•---.... -----•------------------------------------------------------------...---------------•--------. <br /> Contractor's. Name 6Q__U h .!�' ).....----.--•............................................................ ................................ Phone----.... <br /> Installation will serve: Residence Apartment House ❑ !!Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ` <br /> Number of living units: ..... Number of bedrooms _.--l.. Number of baths .../-- Lot size --------.---/A.r,__x...� --_________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ._ ft. y�,�A,L <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,dote--------------------) No ❑ New Construction: Yes ❑ 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 /> Septic Tank: Distance from nearest well-----------------Distance from foundation----................Material-------------.................................... <br /> ❑ No. of compartments--------------------------Size..........-•--------------------Liquid depth--------------------------Capacity.....--•............... <br /> Disposal Feld: Distance from nearest well-----------------Distance from foundation....................Distance to nearest lot line................. <br /> ❑ Number of lines-----------------------------------Length of each line----.-----------------------..Width of trench----------------------------------- <br /> Type of filter material_________________________Depth of filter material------------------ <br /> T-Total length......................................... -J <br /> Seeps it: Distance to nearest well______._�------Distance fro fo ndation -.- 7/...._..Distance tp nearest lot lin 7_-.-tom______ N <br /> Number of pits--------f------------Lining material-- -- . _,Size: Diameter-----(0._.Yb..-..Depth ------f---------------------- <br /> ­­ <br /> Cesspool: Distance from nearest well----------------.Distance rom 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----------------------------------------------------------------------------------------------------------------------•------------_------ <br /> a <br /> Remodeling and/or repairing (describe)---------------- ... ------- ------- ------ F` ...................................... <br /> ------------------------------------ ------------------------------------------------------------------------------------ <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, and rules and regulations of the San Joaquin Local Health District. <br /> i Owner and/or Contractor <br /> (Signed)------ . ---- <br /> ----- - - ------------ ( / <br /> BY ----------------- -----------------------................-------------------------------------------------(Title)---------------------------------------------.... -.----•--•--- <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-------------- ------------------------------------------•_.-----�r- � DATE j� r ----- <br /> REVIEWEDBY------------------------------•-----------------•-------------------------------------------------------- -- DATE.-------.. ..--•---.....-----------------•----------------- <br /> BUILDINGPERMIT ISSUED----------------------------------.-•----•---------------------..................... -•------------._ DATE.._.---- .......__...--- _--------••-----•----- <br /> Alterations and/or recommendations;---------------------------------------------------------------------------------------------------------------------•----•------------------------------------ <br /> .............................'-•- ------------------------------------ -----------------------------------------------•---...------.------------------------------------------------------------------------------------------ <br /> --------------------------------- <br /> -----•------------------------------------------------------------------------------------------------------ ------------•------------------------------------------------------.....•---•--------------------------------._.. <br /> ----•-•-•------------------------------------------------ --------R=---------------------------------------------------- ------.---_---- --------------------------------------------------------- ---------------- <br /> b � � ,�w <br /> FINAL INSPECTION BY..' " r� «s. ------- Date---------- `��: -' ------- --------------•--------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />�" <br /> ES 9 REVISED 6-39 PM 681 ATLAS � ' <br />