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r FOR OFFI ETU <br /> APPLICATION FOR SANITATION PERMIT Permit No. .,1-�...�....��� <br /> ----------------- -------------------------------------- (Complete in Duplicate) <br /> Date issued .A_/�iv��------------------------------------------- =- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the-S—J <br /> oa`uin Local Health District fora per+rtiit to construct and install the work herein described. <br /> This application is made in nc" my Ordinance o. 549. <br /> JOBADDRESS AND L0�1ON' ---- ....-•-----------------------------••--• ----....----•------•- �---------------------------------•--- -•-----•-••-•---•----------------------------------° <br /> Owner's Name &-�o-�l ---'- --------•------- --- F ` ''— �-----. Phone-= <br /> Address..............///.4?. _�/'....�(- rz <br /> Contractor's Name------- ----------_----------------------------------------------------------_--•----------------------- Phone................................... <br /> -Installation will serve: Residence [Apartment House ❑ Comrnercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ._I... Number of-bedrooms __;2_ Number of baths 1.... Lot size .-.•------------------- <br /> Water Supply: Public system..❑ Community system ❑ Private ❑ Depth To Water Table 4�ft. , <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: ilf yes,date--------_----------I No.'e/ 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 Distance from foundation__1 .'.._.-------Material----__L2P ' °`........................ <br /> [� No. of compartments----A'----------------Size--- _ 1'-----•---Liquid depth------ ------.-CaPacitY- n® <br /> , <br /> Disposal Field: Distance from nearest well----- -------Distance from foundation___11'_-------_Distance to nearest lot line___;-:......... <br /> [ � Number of lines.......---------------------------Length of each line-If-f---------------------Width of trench.--.-- .........._------.--- <br /> Type of filter material'_XkA---------Depth,of.filter mate rial___1&..'._"---------Total length._____2Q__-------------------------- � <br /> ti <br /> Seepage Pit: Distance to nearest well.---------------------Distance from foundation.1.0..--_....:...Distance to nearest lot line.---5�_---._ <br /> p f--------------Lining material <br /> --- �: AC-__.Si e: Diameter-_.- - Dept h---.--- -�..- __ O <br /> Number of its---.-- <br /> , ,- � <br /> Cesspool: Distance from nearest well f--....-.Distance from found ion------------------- Lining material-----------------------------------. <br /> r_1 Size: Diameter--------------------------------------- ----------------- -------•------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-'- ----------------_-__. building-----.-, <br /> Depth =- <br /> -------------- ----- Distance"from nearest building- ----•---------------•----•--•----••--•- nl+ <br /> - -- <br /> ❑ -`> Distance to nearest lot line------------------------------------------------ <br /> Remodeling and/or repairing ;(describe:-------------------------------.---------------- <br /> r <br /> ' ... t <br /> -----------------------------------------i----•--------------------------- <br /> -----------------------------------------------7-----------•-------- <br /> { <br /> 't I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, State laws, and rules and re do of the San Joaquin Local Health District. <br /> (Signed)------------------------------- -- -_ ---- ----- - - --------- - --------------------------- ---------------------------------------------------(Owner and/or Contractor) <br /> By:----_-------------------------- - -- ----- ---- -----(Title)------------------------- <br /> (Plot plan, showing size of lot,ilocati n of system i the <br /> to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> r APPLICATION ACCEPTED gY = DATE "'... �'�, '- <br /> ------ ------------------ - --------------- <br /> REVIEWEDBY------------- ---------------------------- -----------------------------------------------------------------._ DATE----------------•----------------------------.._.....-.-:--. <br /> BUILDINGPERMIT ISSUED....................................................rr ! - - :--�-----------=..-.-`--'-�--'-�--r--�-----`-�-------------- DATE-------•------•^--�--`----/---L---K--3-{•---�-z-------1-.�-.-.-.-.-.� <br /> --------- <br /> - <br /> Alterations=and or recommendations:---- <br /> - --.---er�`----- ------------------------7_­1...... ---- ------------ <br /> ----- <br /> -—-------------------------------------------------------- ----------- ------------------------------------------------------•-------------------------------- <br /> ---------- ---•----------------------------------------------------------------•----^----^--•--------------------------------------- <br /> FINAL INSPECTION BY:---- C --- Date-------------. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 305 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8.59 2M 5-62 ATLAS <br /> -. j <br />