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F R OF ICE USE: <br /> 9 ` APPLICATION FOR SANITATION PERMIT Permit No. ___. :__ l <br /> (Complete in Duplicate) <br /> Date issued ___ ��2__ _ <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 construct and install the work herein described. <br /> This application is made in compliance with County Ordinance �Noo, 549, <br /> JOB ADDRESS AN A ON-�_- <br /> OCI - ---- -_._!_ _!-fCY 'l/t ------------------------------------------------- <br /> -------------------------------------------------- <br /> Owner's Name-------- ----------------------------------------------------------- - ------ ----- ------------------ Phone----------------------------------------------------------- <br /> Address------------------- -------- <br /> Contractor's Name--•---- , - ._.. _ Phone.... <br /> Installation will serve: Residence//�partment House ❑ Commercial E] Trailer Court ❑ Motel E] Other E]Number of living units: ___!-__ Number of bedrooms _Z__ Number of baths __/__ Lot size �~ <br /> -- - - -- --- - ----------------------------- <br /> Water Supply: Public system ®--t-ommunity system ❑ Private ❑ Depth to Water Table 4K <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g]-- ardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No ® "New Construction: Yes ❑ No [R--"_FHA/VA: Yes ❑ No 9�— <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 /> r+fg7�6�Z�I No. of compartments------- ----- ------------Size-------•---------------.--------Liquid depth--------------------------Capacity---------------- ------ <br /> f <br /> Disposal Field: Distance from nearest well '­__Distance from foundation, p_ ___.___Distance to nearest lot line_--�______ <br /> f <br /> Number of lines______--�-_.-_ Length of each line-__14-49 __ ____ Width of #Tench__4__-------------______________ <br /> Type of filter material_ � _Depth of filter material---� ��--------Total length____-_Q___ ___________ __ <br /> ---.----- <br /> Seepage Pit; Distance to nearest well--- '_----------Distance from foundation_•,?_4�7___.Dis a to nearest lot line.d�41____.- <br /> ®� Number of pits------/_-_______-Lining material-_/hD�4_.-Size: Diameter ----------- -_____________-____ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation__________ _Lining material-_____-__._____-________-_____--_-___. <br /> ❑ Size: Diameter--------------------------------------Depth---------- ----------------------------------------Liquid Capacity-.--------------------------gals. W <br /> Privy: Distance from nearest well-__----------------------------------------_-----Distance from-nearest.building----------------------------------.____._. rn <br /> ❑ Distance to nearest lot line--- ---------------------------------------------------------------------------•--•------------------- <br /> Remodeling and/or repairing (describe) _9 ------------------------------------------------------------------------------- <br /> ---•----•-� ----------------•--------------------------------•-•---------•--------------------------------------------- -------------------------------------- --------------------= <br /> i <br /> rO <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 regulatio s of the San Joaquin Local Health District. <br /> (5igned)----------------------- - --- -- - ------ - - -- ---- ------------------------- ---- ---------------------------------------------------(Owner and/or Con#Tactor)By:.- -------------------------------•-------------------------- -- (Title)--�s.1�2 -- =------ <br /> (Plot plan, showing size of Iof, location of system`i elation to wells, buildings, etc., can be placed on reverse side). <br /> r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------- c ----------- DATE--------- - --�------* -------------------- <br /> REVIEWED BY------------------------------- --- ----------------------------------------------------------------------------------------- DATE---•---------------------------------------- <br /> ------------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------r•- � <br /> ------ DATE----------------------------------------------------•-------- <br /> Alteration--anVrec m endations:__-_-_______________C� <br /> --------�- ---- -------- ---1 � ....... --- <br /> -- -- -- ----- -- ----- --------------------------------------------------------- --------------------------------- <br /> -_ ------------------------------------------------------------------------- ---- . . . ...---------------------------------------- <br /> ------------------------------------------------------------------------------ --------------------------------------------- ---------------------------------------------------------------------------------------------- <br /> ------------------------------------------- <br /> FINAL INSPECTION BY:----- ---"----� -------- - ---- ------ - - Date------------ ------------- --- -- - - ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124.Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California '— Monte co,California Tracy,California <br /> ES 9 REVISED B-59 3M 3-'63 F.P.00. <br />