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FOR OFFICE USE: <br /> ____ <br />----------------------- ----------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit o. ........... ......... <br />------------------------- ----._ (Complete in Duplicate} Date Issued ... Z <br /> ___________ This Permit Expires 1 Year From Date Issued ct3�Zia o/ <br /> Application is hereby made to the San'Joaquin Local Health District for a permit to construct and install the work herein ascribed. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATI5- ............ -----•-127 <br /> --------------- <br /> _ Phone./Ve L <br /> Owners .Name-------------------- <br /> ,�.:,� <br /> Address------------------------•---... � ...------------•--------------- <br /> ��...----.--r--------�X---------- --�-- -------- - ---- -- -----•------------ <br /> Contractor's Name___________________ _ c_-•-•--• • Phone <br /> Installation will serve: Residence 0--�+partment House ❑ Commercial E] Trailer Court [IMotel E] Other [3 W <br /> Number of living units: .___ Number of bedrooms,3__-. Number of baths .!t —Lot size --------- ---------_sl <br /> Water Supply: Public system ❑ Commuriity system ❑ Private [3—Depth To Water Table �_.ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam Q—Clay Loam C] Clay ❑ Adobe❑ Hardpan C] <br /> Previous Application Made: (If yes,date--------------------I No [�JrNew Construction: Yes El—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__ S"- Di stance from foundation.... '_______.Material----- <br /> ------------------------ <br /> �--- <br /> �r No. of compartments____ .._._-__� .__--Size.___ j.---.---Li Liquid de th________ Ca aci ______________ <br /> __ _ <br /> Disposal Field: Distance from nearest well------ Distance from foundation-------2—_«---Distance to nearest lot <br /> Number of lines-------------7———------------Length of each line---------- .......Width of french---------...x—=--------------�� <br /> Type of filter material.` ---Depth of filter material___-�r---�---Total length................ --�•--------• <br /> Seepage Pit: 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 found ation___._.__---_______.Lining material-------------------------...... <br /> ...... <br /> ❑ Size: Diameter.----i--------------------------------Depth-----------------------------------------------------Liquid Capacity gals, <br /> Privy: Distance from nearest well _____________________--_.___.______-__.------Distance from nearest building-------------------------.---------------- <br /> . ; <br /> i <br /> Distance to nearest of 8------------•------------ --------------- - ----•------------•-----------•-------•-•-- <br /> ----------------------------------------------------------------------- <br /> m <br /> ( <br /> Remodeling and/or repairing (describe):----------------------------------------------------- ••-------------•-•-----•--------------------------- <br /> 4 <br /> ________________________________________________________________________________ <br /> ________________ _______________________ <br /> ------------------------------------------------------------­!---------------------------------------------__------------------------------------------------------------------------------------------------ <br /> -- <br /> ___________________________ ________________________________!______-__---_____»____-_._____.-._____-_____-._....-.____-_-_____.________---____--_____--_______________-_-__-______.___...____________________.__.___.___.. <br /> I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County <br /> ordinances, Sta+ laws, andel rules and r rof <br /> the San Joaquin Local Health District. <br /> (Signed)---- - , I -------•----------------------------- (Owner and/or Contractor) <br /> - ----------- ----- -- - <br /> By:---•-- --- -----•• <br /> ------ ----- ---- <br /> (Title) --------- -- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> PARTMENT USE ONLY �' <br /> Ix <br /> I APPLICATION ACCEPTED BY-------------- ---- ------ ...... ..It-o- --------------------------------------- <br /> -- DATE rl �- ---- <br /> REVIEWEDBY__... -----------------•• DATE----------------------------------------•------------------- <br /> IBUILDING PERMIT ISSUED-------------------------------------------------------------- ---------------------------• DATE------------------------------------------------------------ <br /> Alterations and/or recommend'a+ions--------------------------------------------------------- -------------•------•----------.-........_-_---------._....----------- <br /> ------- ---- <br /> _............. <br /> .... --------------- <br /> i, ,��t �! -�� '" ------------------------- <br /> FINAL INSPECTION BY:. r ----•- ------------•-- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> I Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 8.59 2M 5-62 ATLAS <br />