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FOR OFFICE USE: <br /> ------- -----------------I----------------I------------- <br /> q ,7 <br /> ------------------------ -------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> -------------------------------------------------------- (Complete in Duplicate) <br /> ----------------------------------------------- I This Permit­E- es <br /> ir" I'Year From Date Issued Date Issued f Xp <br /> Application is hereby made to the San J 2_0,9'_,), <br /> oaquin Local Health Dist rict for a permit to construct and 0_/ Z_ <br /> This application is.maclajn_complia�ce with County Ordinance No. 549. install the work herein described. <br /> JOB ADDRESS ANDeCATION.N W...0r, <br /> ----- •-------------------- --- - ----- ----- <br /> Owner's Name--- ---------- <br /> --- ---------------- -----------------------------------------Phone.--------------------- <br /> Address,,,----------- ----------------- <br /> Contractor's N8'me_-M <br /> q T_Er <br /> ------ - ----------------------------------_----- Phone.................................. <br /> Installation will serve: Residence ET-Apartment House 0 Commercial [I Trailer Court ❑ Motel [I Other <br /> Number of living units- Number of bedrooms -Number of baths .-/--- Lot size <br /> "rr .rf:- I <br /> ------------------------- <br /> Water Supply: Pu V4 <br /> Public system C] Community sy m El Private [Dept Water Tablet. <br /> Character of soil to a depth of 3 feet: Sand Community <br /> El Sandy Loam Clay Loam <br /> ��c Clay [I Adobe(3 Hardpan <br /> Previous Application Made: (if yes,�Iate------ -------------) N6" Er" New Construction: Yes PHA/VA' : Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS <br /> (No septic tank or cesspool p;rmiffed if public sewer is available within 200 feet.) <br /> Septic jern k: Distance from nearest ----6stance from foundation----/0-----------Ma�tae,ial_60NRE <br /> RT No. of compartments----------__21------------Size__aX_�?A_=,..Liquid depth""..._ <br /> Capacity.- <br /> Disposal ield: Distance from nearest -Distance from foundation....A9------...Distance to nearest lot <br /> Number of lines-!. ---- <br /> ----------------Length of each line-------- Width of frerich------ /I <br /> Type of filter material._,R_0_C)-k'.___Depth of filter material------_".-_".".....Total length-.--,-1./ - ----------------- <br /> --------------------- <br /> Seepage <br /> ------------I-----Seepage Pit: Distance to nearest well--_-"-_ Distance from foundation-------------_-----Distance to nearest lot line--..----_--....__ <br /> El Number of pits-"'-------------------Lining material-----------------------Size:Size: Diameter <br /> f 1--, _Depth----------- <br /> a -------•'Distance from foundation--------------------Lining material__':_".---" !N: <br /> Cesspool: Distance from nearest well-------- - --.-------- <br /> El Size: Diameter_ i 'DeO h----------------------------------------------------Liquid Capaci ' <br /> --------------------------------- <br /> ty__1 --------------_----ga <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 /> --------------------------------------------------------------- ------------------------------------------------------------ <br /> i ---------------------------------­1----------------------------------------------I.......... <br /> --------- -------------------------- ------------I—-__ t <br /> 'I--------------------------*----------------------------------------------I.:-------------------------------------------••-----------------•---------------- <br /> I hereby cerfif �at I have prepaied this app'cation and that the Work will be'done in accordance with San Joaquin County <br /> I <br /> ordinances, Stat aw rules anir-reg ZAtion f,t an aquin Local Health District. <br /> --fSigned)-­ -,---------- - -------- -------- --- <br /> -------- ----- --- ---------------------------------- ---------------------------------- rLfor) <br /> and/or Cbrritrador <br /> By:--------_------------------------------------f .. <br /> --- ---------------------------------------------------- <br /> -- ----- ------- - ---- --------(Title)------------------------r----------------- -- ------------------ <br /> (Plot plan, showing size of lot, locatio' of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- DATE__.._,./Z^;2� <br /> REVIEWEDBY-------------------------------- ------------------ ----------------------------------------------------------------------.__ DATE------------- ------------ <br /> ------i-------------- -------*--------------- <br /> BUILDING PERMIT:'ISSUED--------- ........I--------------------------- -•----------------------------------------------------- DATE--------------------- <br /> --------------------------------------------------------------------------------I----------------------- -------- <br /> Alterations and/or'recommendations:" """"-.."-""".--__"_""-"__"---------- <br /> ---------------------------------------------------------------- -----------­1----------------- -----------------------------------I----------------------------------------------- --------------------------------------- <br /> -----------­----------- -----------•.--...--------- • --------------- -------------------------- --------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- ............. <br /> ----------------------- <br /> ------------ ---------------------------------- - ------- ------- ---------------- ------- ---r,�-----------------------------------------------------------------------_-:;- <br /> - -- - ----- ---------------- - ------ ---I-- ------I - --------------------------------------------- ------- ------- <br /> ---------------------------------------- <br /> --------- <br /> FINAL INSPEC BY:. .1 ---- ------ ----- --- - -- ------ <br /> -- - Date .... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 730 South American Street 300 West Oak Street <br /> 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 2M 5-62 ATLAS <br />