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FOR OFFICE USE: <br />--------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> _ .. . d <br /> ----------------------- <br /> ✓l` <br /> (Complete--in Duplicate)'. / <br />-------------------------------------------- - - -- This Permit Expires 1'•Year, From Date Issued <br /> Date Issued .-••-...........l(�1 <br /> Application is hereby made to the San Jo quin Local Healfh-Districf'for,a'permit to construct and install the work herein described. <br /> This application-_is made in compliance with County Ordinance No. 549. (P03 - /3 v -@/ <br /> S1 15<7 .coq-e_ ., 4 <br /> JOB ADDRESS AN LOCATION A_-- _._� <br /> Owner's Name. " Q ------------------------------------- Phone <br /> Address. Z. _4F... �r ..--------...................... ---------------- h <br /> Contractor's Name ...... ..... .... �- _ .. Phone----------- <br /> _t___.. __ __ _____ _______________________......__.-........._..... ............... <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' <br /> Number of living units: ___ Number of bedrooms ..��-. Number f baths __��' Lot size ....... <br /> �.- ,.. --------------------- <br /> r <br /> Water Supply: Public system ❑ Community system El Private Depth To Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel Sand Loam `Cls Loam Clay Adobe Hardpan <br /> �,� P - ❑ ❑ Y ❑ Y ❑ Y ❑ ❑ <br /> - l" Previous Application Made: (If yes,dote_________________--) No ❑ �hNew Construction: Yes ❑ No ❑ 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 /> Septic Tank: Distance from nearest well_________________Distance from foundation._...__..._____.._-.Material-------.._-._.__..-..._. ......---------------- <br /> ❑ No. of compartments------------- ------ -----Size............----------.........Liquid depth------- ---------Capacity----------------------- V . <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation_.................Distance to nearest lot line____________----- <br /> ❑ Number of lines_---------------------------------Length of each line_-_,______________________.Width of trench----------------------------...... <br /> Type of filter material___----------------______Depth of filfer material__---_-..-_-____-_-.---Total length...___-_________--_---_-_____.________--__ <br /> Seeps Pit: Distance to nearest well----- P_4---------Distance from foundation---- Distance to nearest lot line_________________ <br /> Number of pits---------J-----------Lining materia -__.Size: Diameter...... _-r-------Depth--- S__ _________________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> El Size: Diameter--------------------------------- ----Depth._..-------------------•----------------------------Liquid Capacity. ..........................gals. <br /> Privy: Distance from nearest well-_____________________________________- __..._Distance from nearest building--------------------.___.___________._.... <br /> [] Distance to nearest lot line--_-------------------------------------------•----------_------- -•-------••-•----•-•------..------------------•--------- ----------- <br /> Remodelingand/or repairing (describe)=--------------------------------------------------------------------------------------------------------------------------------------------------------- F_ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----•------------------------------ C <br /> +. <br /> --•------------------------•----------•-----------------------------------•------------------------------------------------------•----------------------------------------------------------------------------- <br /> i <br /> I Hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, State laws an rules and regulations of the San Joaquin Local Health District. cc0 <br /> (Signed)----------------- ------------•-------------•-- -------- --------------------------------------------------------------- er'and/or Contractor) G <br /> BY: /��. ----�[�'- f fes+' - ----------------------------------------------------(Title)-------------------- <br /> (Plot plan, showing size of lot, location of stem in elation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> fl ' <br /> APPLICATION ACCEPTED BY------ __________ _ ______ ----------- DATE... '-�q�G ____•-•--__-.-- <br /> ------------- <br /> REVIEWEDBY--------------------------------------------- ----------------------------------------"•------------------------------- ---- DATE--------------- ----....------------------------------------ <br /> BUILDING PERMIT ISSUED---------------!----------------------------------------------------------------------------------- DATE--------------- ----------------------------------------- <br /> Alterations and/or recommendations:-[----- ------ ----------------------------------•----------------............ ------------•-----••--•--------------••--•-------------------------------- <br /> ----------------•-----------------------------------•--------------•----------------------------------------­1-------------------------------------------------------------------•----------------------------------------•- <br /> •................•----------......_...._..._-.------•------------------------------------•-------•--- -----------.......----•----------....._...--------•-•-----•-•---------..........----------_._._....._......----•_.... <br /> -------------------------------------------------------•------ <br /> ----- . <br /> ------------------------- ------ ------ - -- ---------------------------------- -----------------------•-------------- --------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:-- -------- ---- 4 --.------- ._ `` --`--- Date.....F'---a ------! �L--------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 144 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,Callfornia Manteca,California Tracy,California <br /> ES 9 REVISED a-59 2M 5-62 ATLAS <br />