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FOR OFFICE USE <br /> ------------------------------------------------------ <br /> d Q� �V er r-e�k--N N 2 ( � 7 <br /> ____________________________.___-___.-_-_.___._-.._.__. APPLICATION FnR SANITATION PERMIT Permit No. ... .. /3.... <br /> ------------------------------------------------------- (Complete in Duplicate) ( 3 / -Z,...- <br />--------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 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. 549. <br /> JOB ADDRESS AN L CATION. B'['� -------------------- ------------- <br /> � t / `-'-�- : ---------------------- <br /> . <br /> Owner's Name._ G .l �r-'�-- Phone. <br /> r --- ... . .... <br /> �r <br /> AddressQ----•°S ..... ... -� ----.---- .................................................. <br /> Contractor's Name ------------ - ------------------------------------------•--.........•-----•...••.... Phone................................... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: .../.. Number of bedrooms -___lumber of baths /..... Lot size ......(_0...X../_Q.'O...................... <br /> Water Supply: Public system ❑ Community system A Private ❑ Depth to Water Table .1. ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loa mClay Y Adobe❑ Hardpan <br /> Previous Application Made: (if yes,date--------------------) No 91 New Construction: Ye 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.) n <br /> Septic Tank: Distance from nearest well tanyem foundation---f-0?-------.Mat ripl._....-�%8&d.is ....... <br /> No. of compartments...... .................Size.___.. _ .x/�?__)(--.,Z-..Liquid depth__... .ly/...Capacity.,/..2D..O...... <br /> Dis osal Field: Distance from nearest wel -. -___ _ .__ tante from founds ion.................Distance to nearest lot li e .. <br /> Number of lines-__._�------- <br /> _____ _Length of each line. - f Width of trench...P ��._._.._......... <br /> Type of filter material.15_ _ -_______ _Depth of filter material.../g.............Total length...../6__fC_....................... <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 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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin County "V <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)--�&!,t..u! (Owner and/or Contractor) <br /> By:....................................................................................................................................(riitle)------------•--------------•-------- .-------------- <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.................................................................................................. DATE............................................................ <br /> REVIEWED BY --• DATE....... _ 2--•'y <br /> BUILDING PERMIT ISSUED........................................ ------ DATE........ -r........................................ <br /> Alterations and/or recommendations: <br /> ....................................--------------•---------•---------------•-----------------------------------------•-----------------------•---••---------•------....--------------........-----------•---------•......... <br /> FINAL INSPECTION BY-------- ----------- ------ -----.---------------- Date-------------L? <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Wort 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 SM 6-61 ATLAS <br />