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FOR OFFICE SE: <br /> �. - � <br /> APPLICATIONFOR"SANITATION PERMIT Permit No. _.. —--------- 1 <br />------------------I-------------------------------------- (Complete in Duplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued _._. _..1._. ...... <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install thP,,g°k here-f9n9nUrbed. <br /> This application is made in compliance w' County rdinan a No. 549. <br /> 7�'3 <br /> JOB ADDRESS A O ATI -------------- ,------•--•• ---------! j / <br /> Owner's Name-- - - ---------- -- - r------- • ---- -• -- - ---- -------------------•--•----------- Phone................................... <br /> Address.--1.4-----�----------- -------- <br /> Contractor's W <br /> Name------------ - -- ---------------------------------------------------------------- Phone <br /> will serve: Residence ❑ Apartment House ❑ Commercial ❑ Traill�❑ Motel ❑ Other w' <br /> Number of living units: _------- N 'or of bedrooms -_-__-_ Number of baths _.._ o size ......... <br /> ____._ _ ________________ _______________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth To Water Table 4;0 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam lay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date.........----.------) No ❑ New Construction: Yes ❑ NoFHA/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 /> tic ank: Distance from nearest well-----------------Distance from foundation-----_..............Material--_-_--------_-----_----------------._.---.----. <br /> No. of compartments------------ -------------Size----------------------_-------Liquid depth----------- •-----Capacity------------•------•J <br /> Disposal Fie d: Distance from nearey <br /> ell� -Distance from foundation--------------------Distance to nearest lot line...:.�..... <br /> i <br /> Number of lines________ _ _ __ Length of each line...-_��____.._ ...Width of trench._____Type of filter materij./ _Q- --Depth of filter material....._- Total length___________________________ __ ___ I <br /> } Jr <br /> Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-_-------------- <br /> Number of pits----------------------Lining material.----------------------Size: Diameter-------------------.---Depth----_-----.-_----------------•- <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--------------------- --- -----------------------------•-•---•-••--••---•--------------------------------------------------•-------- <br /> Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------•----•-.-----------------------------------------------------------------------------.------------------------ ...._......------•----------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------....-.....--•--------------------------------------.-.......-...------------------- <br /> ------------------------------•-----------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------.. . ......... <br /> I hereby,c y that I have prepared this application and that the work will be done in accordance with San Joaquin County t <br /> ordinances, S to aws, aQd r les and re ations of the San Joaquin Local Health District. <br /> [Signed)- -- ------------ -- ---- ------------- - ------- - ------ Owner and/or Contractor) <br /> By:............................................ -----•---- [Title�� ►�/ f <br /> (Plot plan, showing size of lot, location of system in relati n to wells, Wings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- - -J----- - - ` --------------------------------------- -•---- DATE---= <br /> REVIEWEDBY-----------------•-----------•--------------------------------------------------------------- --•---------------------------- DATE--------------..---•-------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------------------.........------------------- DATE------------------- •----------•-------- <br /> Alterations and/or recommendations:-------------- -------------- ----------------------------------------------..--....-----------•-••----•-•----•-----...-•---•--•--------•-----__-••---------- <br /> •--------- --------•--------------------.----------------------------------------- ------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------ - ------------------------------------------------•-------------------------------------------------------------•--- <br /> -------------------------------------------------------------------------------------•----------------------------.----•---------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:. /v/,- �`-"_._�_-------•----- Date------ �.-------------__ ---•---------------_---_- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 144 Sycamore Street 405 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8.59 2M 5-62 ATLAS <br />