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AMLICATION FOR SANITATION PERIv1TPPermit No. <br /> - -- -- - - - --- - - - - - --- - ------------•----•- <br /> Date Issued Y 1 2w-------------------------- ----------------------- (Complete in Duplicate) &CL <br /> 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.Co t ce�oo 49 <br /> >' `' �" 'd '� '"' •-••-•---------------------------------------------- <br /> JOB ADDRESS AND LOCATION.... _ ______ ___________�__ ,�' __.___ _ __ <br /> Owner's Name 3� - ----•-•-----------------•------------- <br /> --- Phone------------------------------------ <br /> Address .. t ✓�--------•--. c ----------------------------•--••------•----•---•----------------------- <br /> Contractor's Name--- X== -------------------------------•-- Phone----------------------------------- <br /> Installation will serve: Residence [I Apartment House E] Commercial ❑ Trailer Court E] Motel ❑ Other El <br /> Number of living units: 1------- <br /> Number of bedrooms __-_ Number of baths _1----- Lot size ------c--'-Z--A ___________________________ <br /> Water Supply: Public system El [Ipp <br /> Community system Private 2 Depth to Water Table P .- ft. <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,date--------------------) 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--- Distanc' fro foundation-----Ia_------Mate rIar------------------------- <br /> No. of compartments_.-_.2-__._-__ Size f��_1- --Liquid de th____.__- -------- Ca acityl-�--- <br /> -------- <br /> Disposal Field: Distance from nearest well.!4�1b--------Distance from foundation---Z0_---------Distance to nearest lot line___----____-__. <br /> I Number of lines_____0.7-_________________________Length of each __:-_______._.Width of trench_�--__ _.__..._._______--__-__ <br /> Type of filter mate riea -:fo -Depth of filter material---f_�__---------total length--_ _4�74----------------------------- <br /> _ Seepage Pit: Distance to nearest well__,'T1---____-__Distance from oundation__/A'•-___-_-.Distance to nearest lot line__.__----___-.._ C <br /> Number of pits._..-_--.-______Lining material. _-__..Size: Diameter-_� -----------Depth.AS_`..'__________________ C <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"dearest building---------------------------------------.-. <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------- -------------- ----------- <br /> Remodelingand/or repairing (describe):--------------------------------- -----------------------------------------•--------------------------=------------------------------------------------- <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 N I' <br /> d regulations of the San Joaquin Local Health District. <br /> / r <br /> Sanedces, State laws, and rulestan�f` --•-t - ----- ��`-. -/r-_----_--'-----------------------'------------ --. - (Owner and/or Contractor) <br /> (Signe <br /> ) �? 1.�. <br /> �1 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 /> APPLICATIONACCEPTED BY �.+ z -------------------------------------------------------- DATE---- l---- ------------------------------------ <br /> REVIEWED BY------------------------------------------------------------------------------------ := _--------- E <br /> ---- DAT ---------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:--------------------------- -- ---------------•-------•----------•-----------------------------------------•-------- -------------------------- <br /> . <br /> --------••- �--- <br /> ---- <br /> ---------------- <br /> �- ----- <br /> ------------------------------------------------- — - o r <br /> = <br /> ---- e ------•---------- -f <br /> ------------------------------------•----------- ----------------------- --------------------------------------------•--------------- <br /> ------••-•--------•------•-------- -------------------- -••----.----•-----------------------------•--------•--------------•-- ----------------------•-------------------- ............ - - <br /> . -------------------------------------------- <br /> FINAL INSPECTION BY: L.:1_? 2.1 = Date-- -t�------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> + ES 9 REVISED 9-59 3M 3-'63 F.P.CD. <br />