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FOR OFFICE USE: <br /> ----- ------------------------------------ - __1........ C12 <br /> ----- -- ---------------------------------- --- - ------ APPLICATION FOR'SANITATION PERMIT Permit No. ........................ <br /> -------------------------------------- ........ (Complete-in Duplicate) <br /> ------------------------ - ------ This Permit Expires I Year From Date Issued Date Issued 11—�7,,7---A- <br /> �,7 <br /> ----------- <br /> L <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 /> I pe?,01 <br /> JOB ADDRESS AND LOCATION----------- --- <br /> ------ -- ------ ----------------/, <br /> --------------------------- -------- ---- <br /> 7 <br /> — - A -- ---- ------ -------------------------------- -------------- Phone. ... <br /> Owner's Name----- IV---e,- <br /> Address----- - <br /> Contractor's Name--------- --------�__ ------------------------------------- ---- --------------------------- ----------- ---- Phone.----- ---------------------------- <br /> Installation will serve: Residence A Apartment House E] Commercial F] Trailer Court F] Motel ❑ Other E] <br /> Number of living units: -1----- Number of bedrooms Number of baths._J--- Lot size ____.I_._7.__-- - ______--______________________ <br /> Water Supply: Public system E] Community system E] Private/4 Depth to Water Table 72-ft <br /> Character of soil to a depth of 3 feet- Sand E] Gravel E] Sandy Loam E] Clay Loam x Clay E] Adobe [-] Hardpan ❑ <br /> Previous Application Made: (If yes,date__..._..._..-.-____ I No New Construction: Yes E:1 No K"? FHA/VA: Yes [-] No E] <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----__-----------Material --------------------- -------------------------- <br /> EJ No. of compartments---- --------------------Size-----•---------- --- -----------Liquid depth-------- - ------- Capacity------ --- ------------ <br /> Disposal Field: Distance from nearest weII_%_5__ Distance from foundation-1-Y'_ Distance to nearest lot line-A-0------- <br /> Length of each line-- 16 -----.-.Width of trench------ <br /> Number of lines ---------------- 6 ----- --- / <br /> Type of filter material____--.K10'ze4___Depth of filter maferi/l-------------------Total length---- <br /> Peg------------------------- <br /> Seepage Pit: Distance to nearest well--------- -----______Distance from foundation--------------------Distance fo nearest lot line____-_______.____ <br /> ❑ <br /> ine----------------- <br /> F1 Number of pits--- ------------------Lining material---------------------- Size: Diameter...--------------------Dept h......___ _---------------- <br /> Cesspool: Distance from nearest well _____-__-.-__-_Distance from foundation................. . Lining material__._.....---- _-- ----------------- <br /> 171 Size: Diameter- -- ---------- --- ----------------Depth--- - -- --- ----------_-------------Liquid Capacity_.------------------------gals. <br /> Privy: Distance from nearest well--------------------------------------------._ __Distance from nearest building__-.__..______ _.___--___-______._.__-_I INS <br /> ❑ Distance to nearest lot lire ..------ --- - - -------- -- <br /> -7 <br /> Remodeling and/or rep 74 <br /> --------------- <br /> .airing (clescribe)�-------------- <br /> ---------------- —----------- ---------------------------------------------- - -------------------------------------- -----------•----------------------------------------------------­1----------------------------------------------------------------------------------------------------------------------------- --------------------- <br /> ---------- -------------1-------- -- - I-----------------------------------------------------------------------------------------------------------------------------------------I----------------- --------------------- - - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)--------- .7 --- ----------------7 -- ------------ ------------------- -------------------------- --------(Owner and/or Contractor} • <br /> By:_.../------------------------------------------ ---------------- - ------------------------------ -------------------------------(Title}----------- ----- -------------------- - - ----------------- <br /> (Plof 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 /> k* <br /> APPLICATION ACCEPTED ---------- --- ------------------------------------ DATE... 7 <br /> ----------- d <br /> - -- - ------------------------ - - <br /> REVIEWEDBY.------------------------ ------ ................. -------------------------- --------- -------------------------------------. DATE__ <br /> BUILDING PERMIT ISSUED-------- ------------------------------------------- ------------------------------------------------ DATE <br /> Alterationsand/or recommendations---- ...... ..._ - - - -------------------------------------- ----------------------------------------------------- ----------------------------------------- <br /> ----------------------------------------------------------------------­­...................­------------------------------------------------------------------------ ------------------------ ---------------------------- <br /> --------------------I------- -------------------- - -­---------------------I—-------­­ - --------------------------------------------------- --------------------------------------------------------------- --------- <br /> -------------- --- ----------- - - -------------------------------------------------- -- -- ----------------------------------------- ------------- ------ --------------------- <br /> ........... --- - ---------------------------------- ------------- --- -------------------------------­­­------- ----- ---------------------- ------------ - -------- ------------- ---------- <br /> FINAL INSPECTION BY: ..... Date.....: -�7 <br /> --------------- --------------- -------- ........ <br /> ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vonguard Press <br />