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FOR OFFICE USE: <br /> ----------------------- ----- ------------------ > q <br /> --------------------------------------------------------- APPLICATI� FOR SANITATION PERMIT Permit No. ..1.. :.../?..� <br /> -------------------------------------------------------- (Complete in Duplicate) <br />--------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued .....f. f...___.... <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 /> , <br /> JOB ADDRESS AND LO TION .... A <br /> ---- <br /> Owner's Na../ ...----•-•-•-------- / <br /> Phone....-•---•-------- ............... <br /> Address.... .... ...... :_ /----••••--- -- -•--- ........................................ <br /> Contractor's Name...................... .... ... __ ..._....... Phone................................... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -.t.... Number of bedrooms ------r Number of baths I...... Lot size .......S10-..Xs...,�.Q.Q--------_--_------- <br /> Water Supply: Public system ❑ Community system KPrivate ❑' Depth to Water Table 3._.. ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam A Clay Loam ❑ Clayg 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. anc from foundat n--•-•1-Q---•---.. erial------�,�./►,�lcsrlG�.. <br /> No. of compartments---21/.___-._•.._._ ize.-.. .X, _-�5,., .-Liquid de th_&LY. Ca aci ( �+�it ... <br /> Dispos I Field: Distance from neare�ttt ell___ a from foundaf ry,_. .�gi....... Distance to nearest lot line.._...a <br /> Number of lines...... ........ ....... Length of each line._ .21n. <br /> 1..?�t,'�..Width of trench... .')! —<< -- <br /> a c0 <br /> Type of filter material.ST- pth of filter material....�A'1!---------Total length. .Q------------------------- o <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line.......... <br /> ------- <br /> � <br /> ❑ Number of pits......................Lining material-----------------------Size: Diameter.......................Depth................................. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-_.-__---.---------Lining material.................................. <br /> �— <br /> ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------.-Liquid Capacity............................ <br /> Privy: Distance from nearest well----------------•___.___-_____-_._----__-------Distance from nearest building........................................... <br /> ❑ Distance to nearest lot line-------------------------- •----------------------------------------•---------------•---•----•--•--------......--...._...•--..............._.. <br /> Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------•------•-----•-•----.................--------...---••.......... <br /> ....-•.................•-----•----------------•--------------•----------------------------------------------------•-------------------------------------•-----. <br /> ---- --------•------•----------------------------------------------------- -------------------------------------•-------------------------........_..----•---•-----............... <br /> I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, tate laws, and rules and regulations of the San Joaquin Local Health District. <br /> A <br /> ~ <br /> (Signed)--------- ---CGS ViI------i+A--- - -------------------------------------------------------------------------(Owner and/or Contractor) R <br /> By:....................................................................................... -------------------------------------------(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------ ------------------------------------------------------------------------••-•......--••---_. DATE............................................................ <br /> REVIEWED BY - DATE............../--p•-----7.- -----�---� <br /> BUILDING PERMIT ISSUED--•---------------------•------------------------ ------ DATE............................................................. <br /> Alterations and/or recommendations:. -----------------------------------------------------------------------------------------------•-----•-- <br /> ..................................................-----------•----••••-----------------•-•.......-•-------------•-•--•---••-•--•--••--•--•••----•-•--•-----•---••••---•-•---••---•--••-•-•-••--•-----•-----••-•--•-••----.... <br /> ---------•-•-----•------------------------ ...................--....__......--------------------------------------------------------------------------------------------------.....------------................... <br /> --------- ------------------------- <br /> FINAL INSPECTION BY--------------------- 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 /> ES 9 REVISED 8-99 2M 6'61 ATLAS <br />