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FOR OFFICE USE: <br /> ,r <br /> - ' APPLICATION FOR SANITATION PERMIT Permit No. ...!-_l..._...�-. <br /> ............. ----------------- ---------------------•--- <br /> (Complete in Duplicate) Date Issued .. / -•(. <br /> ---------------------------- ------- <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 const; <br /> ct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. l X0-0/ <br /> JOB ADDRESS A D LOCATION 1I' fes' ------`---4 ................... ---------A.; <br /> --- -- <br /> r <br /> Owner's Name--" c *�K.,07.... ....-1c <br /> Address------...a_,P...... •-. 'c�"'-------- -------------------------------------------------------------------- <br /> Contractor's Name Phone............................•------ <br /> Installation will server Residence-Ill. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I <br /> Number of living units: t�...... Number of bedrooms 3-.. Number of baths3----- Lot size .��--�--�����-�41 <br /> -•-•- <br /> _Water Supply: Public system K Community'system ❑ Private ❑ Depth to Water Table �A. ft. <br /> Character of:soil to a.depth of 3 feet: Sand F] Gravel ElSandy Loam] Clay�Loam❑ Clay C] Adobe❑ Hardpan ❑ <br /> . -w. <br /> Previous Application Made: (If yes,date_------------------) No�] New Construction: Yes No [3 FHA/VA; Yes E] 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--;-.0-_---..Distance from foundation._!- .._---._-..Material.. ... ..... ........ .......:.............. p4 <br /> r� No. of compartments------�` ..��Y <br /> -------Size . _ --�-• ---Liquid depth----/-----------•------Capacity-/err ..:--•- \ <br /> Disposal Field: Distance from nearest well-S—q---------Distance fromfoundation.-lP------------Distance to nearest lot line__'_.._----_--Number of C <br /> lines <br /> ---------- ----------------Width length-_�.Ma........................... <br /> - --- <br /> Seepage Pit: Distance to nearest well from foundation..........---------.Distance to nearest lot line...._-_.-.:_-_-... <br /> Number pitsiLining material ------- Size <br /> umer o ------------------k ----------- <br /> : Diameter--------------------....Depth--------------------------------- <br /> ❑ A <br /> Cesspool- Distance from nearest ......Distance from•foundation--------------------Lining material--.-----_-..----__-.-_----..-.....__- <br /> Li uid Capacity gals. <br /> ❑ ' Size: Diameter— -•----------------- :.--Depth-ft- f' ---•-•-------- ----------- 9 p tY <br /> {{ ------Distance from nearest building - <br /> Privy: Distance from nearest well-----._.?1.--�_!'---------------------- - g_--'_-------'-".------__'_'_ .- <br /> ❑ _ --�. <br /> _ Distance to nearest lot Ime-------•--=--•----------------------------------------------•----.......-------•-----------...---------------------------...-------------------- <br /> } ► ---•-----••- <br /> Remodeling and/or repairing (desc'ibe):-------- ------------------------- <br /> --------- <br /> ------------- --- - <br /> ----------------------------------------�: --"-:----------...------------------------------------•-••-•--------•----•-•• -------- <br /> iI - :- --------------------- ---•--------- -.......................-- -- . <br /> f <br /> ----------------------------------------------------------- -- <br /> Ihereby certify that I have prepared this application- <br /> '*'d that"fhe work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules a'nd rregulation& of the.Ssn 'Joaquin};Local Health District. <br /> {Signed} -- ------ ----- <br /> --.�.-s- : ------ ----------------- <br /> -----------------•(Owner and/or Contractor). <br /> '� # (Title)------------•------------------- --------•--- -- ----------------- <br /> By:---------------------------------------- _-----•--------..:::_---_------ ----- . ----- a ----------- <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 /> APPLICATION ACCEPTED BY�1----- ------------ -----J------------------- ------------------•-----------•-------- DATE_. " - <br /> REVIEWEDBY------------------------------------------------------------------------------ -----------------------------------------• DATE...... •----------------•---------••--••-------------------- <br /> BUILDING PERMIT ISSUED--------- ---------------•------------------------------ -------------------------------------------- <br /> DATE------------------------------------------------------------- <br /> Alterations and/or recommend'ations:----------------------------- ---••-----------------------------------•--------------------••------------------------.._-...... <br /> =-----------------------------•--••------ <br /> ----------- --••------------------------ <br /> --•---------------------------------------------- <br /> -------------- -------------- -----------------•---------- -- ------ --- ---------------- --- , . <br /> -------------------------­ <br /> ----- ----- ------•------------------ -•--------------•--------------------•--•---- -------------••-.. ..-------- <br /> ` —I FINAL' INSPECTION $Y:. /y/ Date--..f ' <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strout 300 West Oak Street 124 Sycamore Strout 205 West 9th Street <br /> Stockton,California Lodi,California i Manteca,California Tracy,California <br /> ES 9 REVISED B•59 2M 5-61 ATLAS i.. <br /> �+r <br />