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FOR OFFICE USE. <br /> 3_ .__-.... <br /> _ APPLICATION FOR SANITATION PERMIT Permit No. _ .. <br /> ---------------------------------------- ---------------- (Complete in Duplicate} / <br /> Date Issued ...... <br /> ---- ------- -- ---- --- -------------------------------- This Permit Expires l Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Heali•h District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> _. - , L <br /> - - ...JOB ADDRES D LOC -�--------- ....... <br /> Owner's Name.. <br /> --Av -----"'!------ ------------------------- <br /> ------ Phone...........------------------------- <br /> Address------ ................................. <br /> Contractor's Name - `g------. --------------------------------------- Phone................................... <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ® Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths ........ Lot size ------*`_QCs.re-___________________________________ <br /> Water Supply: Public system B"Community system ❑ Private ErDepth to Water Table __6oft. <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 u New Construction: Yes Er"�No ❑ FHA/VA. Yes ❑ No []1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septi tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Distance from nearest well_________________Distance from foundation-------------------Material-----------------,............................... <br /> ElNo. of compartments----•--------------------Size-----•-•------------------------Liquid depth--------------------------Capacity----------------------- <br /> Dispo J Distance from nearest well-----------------Distance from foundation....................Distance to nearest lot line--------.•---.--- 'V <br /> [I Number of lines-----------------------------------Length of each line..............................Width of french................................... <br /> Type of filter material___----------------------Depth of filter material-----------------------Total length----------------......................... <br /> Seep ,P 't�� Distance to nearest well-1 ----------Distanc m foundation... .Distance to nearest lot line0....-...... <br /> Number of pits____!________________Lining material___-_1.4XA__-___Size: Diameter_..._._..___..___.Depth__.._�s_.___________.... <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------•----- ---_-- -- •-•-Liquid Capacity <br /> ----•---------------•--•----gels. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______.___._________-_-------_.--_.____._- <br /> ❑ Distance to nearest lot line------------------------------------------------ -----------•-------•---------------------•--------------------- <br /> Remodelingand/or repairing (describe):-------------------------------------------------------------- ..............-----------•--•---•---------------------------•------------------_-------- <br /> -------------•---------------------------------------.-------------------------------------------------------------------------------------------------•-----------------------------•---•---------------------------------- <br /> ------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------- --•-------•------------------------------------------------------------------------------- <br /> ! 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 regulations of th San Joaquin Local Health District. <br /> (Signed) - (Owner and/or Cantractorl <br /> By:__... ------- -- • ---------'61--------------------------------------------------ITitle)------------------------------------- ..... <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----- ________ __ ___ "`"` <br /> --------------------------------------------- ---- DATE--- y----1'I - <br /> -- ------------------------------- <br /> REVIEWEDBY------------------------------------------- --------------------------------- --------------------------------------- DATE--------------------------------------- <br /> •---------- <br /> •---•--•-- <br /> BUILDINGPERMIT ISSUED-------------------- t----------------•--------------------------------------------------- DATE-------------------------------- ---------------------- <br /> AFterations and/or re - �- � - `____ lz--_. _. <br /> _ ! --- <br /> -------------•------------------------------------•--•--------------------------------------------------------------------------------------------------------.._...---------•----------- -•---- <br /> -------------•-•------•--------------------- -•----------------•---------------------------------------------------------------------------------- ••---------------------------------------------•-------- <br /> FINAL INSPECTION BY:---°-- 1 ./1 -•- • •--- ------------------------------- Date.......... <br /> -•---.._..----------------------------------------------------•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wert Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 8.59 2M 5-62 ATLAS <br />