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liOR OFFICE USE; <br /> ----- -------------------------- ---- APPLICATION FOR SANITATION PERMIT Permit No. l.xm.5_. <br /> -•--------------- -------------------------- (Complete in Duplicate) (1 - <br /> Date Issued <br /> ---------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> .. ........ <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 <br /> lication is made in compliance with County Ordinance No. 549. <br /> c.Yt�C�E �UE / L i _ <br /> JOB ADDRESS AND LOCAT�I�O� N.�.. ,) � -------` A �` �� ja =' --------•-------••---• <br /> Owner's Name--- k� 1a. .t �C.G / 2 :ate--------------------------- -------------------------------------- Phone.+'-11---3-.- <br /> Address Q11� .. ��.._mC l.!!�L-E `� f <br /> Q 13.Pi....TIH�k�S <br /> 2 <br /> Contractor's Name------—-•----------------------------`` -`- -- ------ <br /> -------/`<< ''� `�- •-------------------- Phone. ------ ........... <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ T aiJer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ________ Number of bedrooms _ __ Number of bath__ Lot size ___ _.,-----— ---_ ._ ._ <br /> - --- ----------- <br /> Water Supply: Public system E] Community system 9 Private E] Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No [] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS; t <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 /> ❑ No. of compartments--------------------------Size--------------------------------Liquid depth------------------------.-Capacity----------------.----- <br /> Disposal Field: Distance from nearest well--200_____Distance from foundation J-0' .._.Distance to nearest lot line-................ <br /> Number of lines-------- ------__________n___ ength of each line______ _____ _____ -Width of trench___-__ <br /> f <br /> Type of filter material... _) lM Depth of filter material...l2�-..........Total length___- -•--------------------------- <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.......................r-_____-_-_-_ <br /> ❑ Size: Diameter--------------------------------------Depth--------------i---------------------------•--------Liquid Capacity............................gals. <br /> Privy: Distance from nearest well________________________________________-------Distance from nearest building_______.____________-___-•---•_-----:_-__. <br /> ❑ Distance to nearest lot line--------- ------------------------------------------------------------- ----------------------------------•------•---------------------------- <br /> Remodeling and/or repairing (describe):--------------- ------------------------------------------------------ -•-----•------•-----------------------------•-•--------••-------•------•-------•- <br /> --•-----------------------------------------------------------------------------------------------------------------.---------------------..-----------..---.---.-----.----..----.---------------•--•---------------------- <br /> 1 hereby certify that I have pr'e ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta laws, and rales an regulations of the San Joaquin Local Health District. <br /> (Signed) .f.(.--- / 6 `` 2 - <br /> ------------------ -------­------..---------------••-----------------------------(Owner and/or ontractor <br /> By-----------------------•------------ -------------------...-------------------------------------------------------•-----`------- (Title)--=-------------- <br /> ------------------- <br /> ....... <br /> ----------------- <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------ ---T-7 3.3-- ------------------------------------------------------------ --- DATE-------- r <br /> REVIEWEDBY--------------------------------....------------------------------------------------------------------------------------------ DATE------ -----•-----------------------•--._.-..._..- <br /> BUILDINGPERMIT ISSUED................. --------------------------•----------------------------•--•------------------------ DATE------...__......_.------------------------------------------ <br /> Alterationsand/or recommend'ations-------------------------------------------------------------------------------------------------•-•--------•--•----------.--------•--------•------•--••-•------- <br /> ------------------------------------------•.---•------.....----• --- <br /> FINAL INSPECTIO ti� Date. "`_ --/---` _ ------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wast Oak Street 124 Sycamore Street 205 Wast 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> 14EVISED B•59 YM 5'51 ATLAS <br /> s <br /> 1 <br />