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FOR OFFICE PSE: <br />--- - -- - ----- <br />___....__ ___ _______-- .....---�/:- APPLICATION FOR SANITATION PERMIT Permit No.--------------------------------------------------------- (Complete in Duplicate) f t <br /> Date Issued .... <br /> -------------- This Permit Expires 1 Year From Date Issued ...1...... .� <br /> Application is hereby made to the San Joaquin Local Healfh • • t for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordin nce o, . 9� <br /> JOB ADDRESSD LOCATION----- ---------1[G ------------------------------- -- ------------------­----------------- ....... <br /> Owner's Name_ s_C-..._. ------------------------------_--- ------------------Tnp�----- Phone-_'�"_ <br /> Address------------A3. - /1 (,O <br /> f <br /> Contractor's Name---=- ---. -. _..------------------------------------ Phone................................... <br /> Installation will serve: Residence C!r Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [j Other ❑ ' <br /> Number of living units: .__�__.,Number of bedrooms '_-. Number of baths _' .. Lot size _� -_(__I_ ........................... <br /> Water Supply: Public system ❑ Community system E] Private [i�Depth To Water Table __L. { <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®-'Hardpan ❑ <br /> Previous Application Made: (If yes,date_-------------- ---) No ff"' New Construction: Yes 2T�No ❑ 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 /> f r <br /> Septic Tank: Distance from nearest well_-:��------Distance from foundation__IP.............Material----------------------.......................... <br /> No. of. compartments_...._..I --------------size......1 b V.q-----Liquid depth----�._............._._Capacity/.Z� _r` <br /> Disposa Field: Distance from nearest well.!-'P--- Distance from foundation�SR!----------Distance to nearest lot line..._._.. <br /> 2 Number of lines.__-.-.I-----------------------Length of each line----J4-------------------Width of trench.-.4Z.$ <br /> Type of filter material._71 c t-_____--_-Depth of filter material__--j_ '_`f----.----Total length---. - ------------------------------ <br /> See pa it: Distance to nearest well-JP9---_---------Distant m foundation-1 -----------Distance to nearest lot line--L5- <br /> Number <br /> ine_-L5-Number of pits---------9__--------Lining material------ G-Lf(----Size: Diameter....33`'.---------Depth_-___, '�................ Q(\ <br /> Cesspool: - - .. Distance-from nearest well_---___---":..-_Distance-from-foundation___.- ------- Lining-material_________ _______________ ........... <br /> ❑ Size: Diameter--------------------------- ----------Depth----•-----------------------------------------------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 /> --------------------------------------------•-•-------------------------.---------.-------------•-•------------------------------------------•----------------------•--------•----•-----------------------I-------------- <br /> I hereby certify that I have prepared this appli ion ci that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations o e n Joaq in Local Health District. <br /> (Signed)---------------------------------------------------- ----- -------- ---- - - -- ---; ---------------------------------------------------------------(Owner and/or Contractor) <br /> ----------------------------�-- -------- - -----------------------------------------------------------Title I <br /> (Piot plan, showing size of lot, location of system in relation to IIs, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- ------------------------------------------------------------------ DATE.... <br /> l i- <br /> -- ....x. . -------- <br /> REVIEWEDBY---------------------•--------- ------- ---------------------------- ------------------------------------------ DATE--------------------------------•-•--------•--------------- <br /> BDILDING PERMIT ISSUED - ------------------------------- DATE .-._...----- ) <br /> Altera+ions end/or r omm ndations _ / -ti�l__' � - -=� �__.__ <br /> - G i. —G <br /> rz <br /> ------- ----•-- <br /> -------- ------ --------------- <br /> FINAL INSPECTION BY:------ - Date----- 1 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak street 124 Sycamore Street 205 West 9th Street (� <br /> Stockton,California i Lodi,California Manteca,California Tracy,California 1 <br /> ES 9 REVISED 5-59 2M 5-62 ATLAS 97Y <br /> 3 <br />