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FOR OFFICE USE: <br /> i <br /> ----- -- ------ ------------ APPLICATION FOR SANITATION PERMIT Permit No. .._-..---• ---•--_-.--. I <br /> -----------­----------------- -------------------------- (Complete in Duplicate) /l <br /> This Permit Ex fres 1-Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constru� install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. 02-5-- 0710- 0 <br /> JOBADDRESS AND LOCA ON_" � -- - ----- - �� ------------------ <br /> Owner's Name--------�fYt-�-- _ �- --- <br /> ------ ----•-------••----------- ------------------ - --------------------------------------- Phone----------------------_ ....... . <br /> Address-------------------•---•- <br /> Contractor's Name------ <br /> / ''t <br /> r :6,e0•-'Phone----•- - 0�7 -------- <br /> Installation will serve: Residence ') Apartment House ❑ Commercial ❑ Trailer CouW E] Motel ❑ Other ❑ <br /> Number of living units: -1----- Number of bedrooms __-3... Number of baths -- __-_ Lot size --- <br /> L <br /> __ ___ ----- <br /> - '______________________________-. <br /> Water Supply: Public system ❑ Cornma�urity system ❑ Private © Depth to Water Table -A--- ft. <br /> Character of soil to a depth of 3 feet: n ® Gravel ❑ Sandy Loam-E] � Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: [If yes,date---------------_--1 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.) C <br /> Septic Tank: Distance from nearest well---�-7- -------Distance from foundation-- / Material-- <br /> No. of compartments---�------------------- Liquid depth--------141-=----t- Capacity__?0-0 ` <br /> Disposal Field: Distance from nearest well-..�0__._._-Distance from foundation.-_,/b_______.,_-Distance to nearest lot line_ <br /> [*] Number of lines-_------/------------------- ----Length of each line------/�.O--------------.Width of°trench_e�__`K-------i-----------_---- E <br /> Type of filter materiaV)o44_-,l;V--/__-_Depth of filter material------Z 4_"_.--;-Total length--__ ____________________ #� <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation_________-i_.---___.Dista ce to nearest lot line----------_--G� <br /> ❑ Number of pits---- ------Lining material-----------------------Size: Diameter ---=-----,= ------Depth------------------'---------- ! <br /> Cesspool: Distance from nearest well-----------------Distance from foundation..................--Lining material---_---------------______._______- t <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------- -1--t f Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well---•-------------- -----------------------------Distance from nearest building-----------------------------------------. r_ <br /> ❑ Distance to nearest lot line <br /> R <br /> emodeling and/or repairing (describe):------. 4 ?' _ _f3 ✓> _ '`- 'j.--------.•----"----------•------------- <br /> ---------------------------------------------••----- --------•---------------------------------------- ---------•------------------------------- <br /> ---------------------------------- <br /> „.�.._ . <br /> ------------------ <br /> ---------------------------------------------------------------------------------------•------------------------`------------ ------------ ------------------------------------------------------------ <br /> I <br /> hereby certify that I havep re ared this application and that the work will be done in accordance with San Joaquin County <br /> ~ordinances, State laws, and rulesnd regulatio s of the San Joa u' ocal Health District. <br /> --- ------ - -- ----f --- <br /> (Signed)-------- -- -- ----- --`- � W�---- --------------- ------(Owner and/or Contractor) <br /> a i^ <br /> By:----------- ----- - - ---- -------�•--- ---------------- -- - ------- ------------------- ---(Title)-------------------- - - -------.. - - - --------- <br /> (Plot plan, showin size of lot, location of sirs em.in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ------------------------------------------------------ DATE--- - — <br /> REVIEWEDBY------------------------------------------------ ---------------------------------------------------------------------------- DATE----------- --------•---------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------ ----------------- DATE---------------------------- ---------- <br /> Alterations and/or recomme dations----------------I--- -- - ---------- ----------- ------------------------ ---------------- ------------.---•- -- ---------- <br /> �------ ------•-------- �� - -u - _----�_0 2 _.e-----el'a-.-x <br /> --------------------------------------------------------------------------------------------------------------------------------------- ------ <br /> ---------------------------------------- --------------------------------------- ---------------- --------------------------------------------------------------------------------------------------------------------------- <br /> ,��� r : <br /> FINAL INSPECTION BY:. ------�-'-��:�--------- - ---• - -------- - Date-- � <br /> ----------- � '--------------- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 1.Haiellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> 9:5 9 REVISED 0.59 3M 3-'63 F.P.CO. F <br /> - 5 <br />