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FOR OFFICE USE: <br /> ------4- 3� / Permit No. <br /> APPLICATION FOR SANITATION PERMIT _ <br /> -----------:,. ----------------- - / <br /> ----------- <br /> ------------------------ (Complete in Duplicate( Date Issued ------ ---y V <br /> -------------------------------- ------- ------------ --- <br /> This Permit Expires 1 Year From Date Issue <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 CAT N__ - ------------=-------- <br /> Owner's Name..._ _ <br /> ----------- <br /> ------- Phone <br /> Address--------- -----�_. .�/r-�- - - ---/t_� - ---------------•-------------- <br /> 1 <br /> Contractor's Name----•-_-- _ Phone----------------------------------- <br /> Installation will serve: Residence UgApartment House ❑ Commercial ❑ Trailer Court ❑ , Motel ❑ Other ❑ <br /> 1c .� _r---- <br /> Number of living units: .__-. Number of bedrooms .-An Number of baths __/__ Lot size ---------------------- <br /> _ � - <br /> Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table �ft. <br /> Character of soil to a depth':of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay.Loam O Clay-❑ 'Adobe�Hardpan C1 <br /> Previous Application Made (If yes date_-------_._,_.-----) No I� New Construction: -Yes ❑ No [R-"FHA/VA: Yes El No �^ <br /> TYPE OF INSTALLATION'AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted-if public sewer is available within 200 feet.) Y <br /> SeRfi4,Tanl: Distance from nearest-well__--' --------Distance from foundation--------------------.Material__.-_-.__--_.__--____---.------.--------_----- <br /> � �l�f�$ No. of compartments------------ -------------Size---------------------------------Liquid depth------------ --------------Capacity----------------------- <br /> a t r <br /> iy <br /> ��- .._,__ Dipt nce to nearest lot line___ ____________ <br /> Disposal Field. Distance from nearesf_well----`r' --_Distance from foundation___--- _ <br /> Number of lines-------- -- --- ---l---�- -,---Length of each 1-::ne_._� �. Width of trench- .............. <br /> ---------- <br /> �� �♦ <br /> Type of filter mateii4- -�---Depth of filter material___ -_----- Total length-.--_- ___ <br /> Seepage Pit: Distance to nearest well_'--_' --------Distance from foundation___ !...-_..Distancd:to nearest lotline-_-sx ------.- <br /> Number of pits---------------�:--Lining material f� ----j------Size: Diameter�9 ,--- '-----;Depth- ---- ------------ <br /> Cesspool: Distance from nearest well'------------- Distance from foundation_...-------'__-.._..Lining material__.--__--_-_--------_--------.____.. v <br /> ❑ Size: Diameter----------------------�-----------:Depth--------------------- -----------------------------' Liquid Capacity gals. <br /> Privy- Distance.from nearest well ==.--- .` __ "---- Dislance from nearest building----------------------------------------- <br /> ❑ Distance to nearest lot line _-.- - <br /> Remodeling and/or repairing (describe)---- ----------� ----- <br /> ----------------------•­----------------------------------------------- <br /> -------------------------- <br /> --- -•------•---- --•----------------••----- •--------_ <br /> I --•-•----------•----------•--•-•-------------•---------------------------•------------ <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 /> 4 ordinances, State laws,.and rules and regy1ations of the San Joaquin Local Health District. <br /> F or Contractor( <br /> ---------------------- <br /> ---------------- <br /> ---------------- <br /> (Signed)------------------------------------------- ----- -- - ---- --- <br /> By:--------------------------------- ------------------•--------------------- <br /> --------------(Title]- -..... <br /> (Plot plan, showing size of lot, location of sys+em in r ion to wells, buildings, etc., can be placed on reverse side). <br /> "FOk DEPARTMENT USE-ONLY <br /> DATE Z <br /> > APPLICATION ACCEPTED BY---- ---__ -------------------------------- <br /> REVIEWEDBY--------------------------------------------- -------------- DATE-------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-----------------------•------------------ --------- DATE-------- -•-------------------------•----------------------- <br /> Alterations and/or recommendations:------------------------- -------------=-`--- ---------•---------• -------------•------•----•--•---• ------------------------•--------------•------------ <br /> --------•-----------=----- ----- ,- - _ - -- <br /> ! G <br /> r • - <br /> FINAL INSPECTION BY.--ie _ �- --�--•. � , <br /> / Date_---- --J----z -r-- <br /> ------------------------------•------------------- <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 /> (9.9 REVIBEO 8•69 r,P.aa.2M 6.60 — <br />