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FOR OFFICE SE: <br />..................... .-------- ____.-------------.----- APPLICATION FOR SANITATION PERMIT Permit No".J.4............... <br /> --------------------•--- --- -------------------------- (Complete in Duplicate) �S�-1 ( G 2— <br /> ----------------- This Permit Expires 1 Year From Date Issued Date Issued ......:.............. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descriled. <br /> This application is made in compliance with County Ordinance No- 549. <br /> JOB ADDRESS AND O ATI 4........ .......................� ` w� <br /> ----- •-----•-------•-••----- <br /> Owner's Name... ---••--•--•----- ---•------------------------------------------------ Phone-----------------................. <br /> Address-.----- -0197- �oo ---- .. ' <br /> Contractor's Name..__ .: .� 'T ---------------------- <br /> -----•-•-•----••---•--•---•------------------------------------------ Phone----------------------------------- <br /> Installation will serve: Residence 0 Apartment House E]'Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _I--- Number of bedrooms Number of baths -----_ Lot size <br /> Water Supply: Public system �ommuriity system ❑ Private ❑ Depth to Water Table .t.D."ft. <br /> Character of soil to a depth of 3 feet: Sand [ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑` Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------l No R-"_-New Construction: Yes LLi' Igo ❑ FHA/VA: Yes ❑ No ❑� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> r <br /> Tan Distance from nearest welly-�__-_Distance from foundation__1.9_..__._____..Material___�...................................... <br /> •' a No. of compartments-,--- 7 PD <br /> Septic P �/.-... Liquid depth----.....tl---•------------Capacity.._ ... . <br /> Disposal Fi d:,: Distance from nearest well_ Distance from foundation__/0_r____.___Distance to nearest lot line ....�...... <br /> Number of lines.............::..'/____--_. _ Length of each line-------- of trench_______ y f__......_......_ <br /> Type of filter material.--_�''G���----Depth of filter material----1r___________Total length------------- O_•___........•....... <br /> Seepage Pit: Distance to nearest well___----__________Distance from foundation___._`___- __-_-___.Distance to nearest lot line..:n--------- <br /> E10 Number of pits-------I-------------Lining material---------- ------------Size: Diameter---- ----------------.Depth-------. ---_.-.--..------- o <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 /> .. �. <br /> Remodelingand/or repairing (describe)--------------------------------------------------------------..................................----------------_....................___----------- <br /> ----------------------------------------------------------------- -•-----•-----------------------------------------------------------------------------------•--•-------.....----------------------------------------------- <br /> --------------------------------------• --------------------------------------------------------------------------------•-------••---•--•-------------...-------------------------------•-•----------•-•-- <br /> I hereby certify that I have prepared t is appli ation and that the work will be done in accordance with San Joaquin County <br /> ordinances,.State laws, and rules and reg a ions o the San aquin Local Health District. <br /> (Signed)........--_------------------------- ---- --- ------- --- - ----- --------...... -••---....-----------------•---------- ------(Owner and/or Contractor) <br /> By......--------------------------------------------- ........................................(Title)---------------------------------------- ------ <br /> (Plat 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 f <br /> APPLICATION ACCEPTED BY--------------------------------------------------------- --------- <br /> ------ �• - ----- !_DC.Z DATE---------- <br /> REVIEWEDBY------------------------------------------------------------------------------------- --------------------------------------- DATE---------------------...--------------- <br /> BUILDINGPERMIT ISSUED--------------•-----......------------------------------------_-------------------------------------- DATE-------- ----...__.----------------- <br /> Alterationsand/or recommendations:--.------- ----------------------------------------------------------•------------------...... -----------•---•-------------------------------•------------- <br /> ----------------------------------------------------•--•--------------------------------------------.------------------------.-.-------------------------....----._......----------------------------------•-- <br /> -------------------•----------------------------......---------------------------------•--- --------------------------------------------------------------------------------------------------------- ------ <br /> ------•--•----- -------------------------------------------•- ....... -------------------------- <br /> FINAL INSPECTION BY---------------- ------- ---------- L'!`--------- Date -­ w <br /> -- - ---- ------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wect Oak Street 124 Sycamore Street 205 Weil 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E9 9 REVISED 8-99 2M 5-41 ATLAS <br />