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FOR OFFICE USE: <br /> ------------=----------------- ------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. /'Ig w= <br /> f -------------- -------- -------- ------------- (Complete in Duplicate) <br /> Date issued ..-.. <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 County Ordinance No. S49. <br /> JOB ADDRESS AND LOCATION] .. = ��� <br /> Owner's Name-------------------- l ' <br /> t <br /> ><x� -- Phone. <br /> iAddress-----•--------------------------------- --------------_ ------ - ----------------------------------------------------------------------------------------------------.........------------ .. <br /> Name----------------------_- " ° ---- ------ Phone----------------------------------- <br /> Contractor's <br /> --••-•------------••--•• <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ . Other ❑ <br /> Number of living units: Number of bedrooms Number of baths -------- Lot size ----------- -------------------- <br /> Wates Supply: Public system g Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑1 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ja Hardpan ❑ <br /> Previous Application Made: (If yes,Idate- __11,0----------) No ® New. Construction: Yes E) No ❑ FHA/VX Yes ❑ No :I <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-_9 --_Distance from foundation---...Z-Q.........Material--------- ----------__---_fJ <br /> ® No. of compartments_.____�---------------Size.......... depth.....--- <f--�---------Capacity___--- <br /> Disposal Field: Distance from nearest well--N 4 -___Distance from foundation....l�?---------Distance to nearest lot line_-.� ......... <br /> Number of lines`-------------/----------- - Length of each line----------?n...............Width of trench <br /> .---••---• - ----------------- p. <br /> Type of filter material-------- 2y _-Depth of filter material------1.9------------Total length-----------Q-a..'----------------`-._ N <br /> Seepage Pit: Distance to nearest,well--- ExxQ -'-_Distance from ounclation-----Ia_ _.Distance to nearest lot line_-.._-----.-_--- 9' <br /> Number of pits.------------------Lining material.__ p <br /> --- Size: Diameter ��-----Depth ----------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material--------------------.,...-____--._-.. <br /> Size: Diameter----------------------- ''-------'-.De th---------•---------------------------- -----------Liquid Capacity gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------•---------------------.------- <br /> ❑ Distance to nearest lot line------------------------------------------------------------------------------------ •-----------•-------------------------------------------- <br /> Remodeling and/or rep firing (des cribe):___T�ce c�e�---�2nt- ? /_ /-/i.--�?!�'/Y7-• -- 1 ✓-- --..5- <br /> (J�hi7_ "-V1 <br /> ----...---•-- <br />' 7`r k..fi-_-_- --_~_C.,.�-V_�___ `___ ------ ----- "= -�-"""-lam ----------5. <br /> - <br /> ---------- -. t _ _ - ---------------- <br /> I hereby certify that I ave prepared this application and­fhai the work will be done in accordance with San Joaquin County <br />} ordinances, Sta j ws, and rules and reg, a s of the San Joaquin Local Health Districf. <br /> F � <br /> {Signed) = --------- (Owner and/or Contractor) <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 /> .4 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------- DATE----s �� - <br /> BY--------------------------------- •- ---- - ---------------------- •--------._...._..... DATE <br /> ------------------------------------------------------- <br /> REVIEWEDBUILDING PERMIT ISSUED-------- r ..-_..... -------------------------- - DATE <br /> Alterations and/or recommendations:---------------------------------------------------------------------------------------- <br /> •-- --------- --- ----------•-------- <br /> r! <br /> ---t- -�� , <br /> =------------ -------- <br /> ---------------------- <br /> --------•----....--.-.._.------------------------ <br /> FINAL INSPECTION BY:..- -- ---- --------------------------------------------- <br /> Date--------------------------------- --------------------------------------------- <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 /> i <br /> E9-9 REVISED 0•69 F.P.0 D.ZM 6.60 <br />