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FOR OFFICE USE: ' <br />----------------- ------------------------------------- <br /> APPLICATION 'FOR SANITATION PERMIT Permit No. <br /> ------------------ -- -------------------------- <br /> ---- ------------------------ ------------------------- (Complete in Duplicate) <br /> Date Issued <br /> ---._ __ This Permit Expires 1 Year From Date Issued <br /> ___. ....... ........ <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 No. 549. <br /> JOB ADDRESS AN'D� OCATION. ]ru �G � <br /> Owner's Name_... y�_�____—___- <br /> Phone------------------------------------ <br /> Address------- <br /> ---------------•---.--------------- <br /> Address------- ..s ....... .... z° ------------ <br /> Contractor's Name_.zf '`-------------------------------------•-----------------------------------•-------•------------------------•--•--------------- Phone--_------••--•-_-_--------•-- <br /> Installation will serve: Residence 4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: r(_____ Number of bedrooms ___ Number of baths _1____ Lot size ............. ____._....--______-._-_-._-____.._- <br /> Water Supply: Public system ❑ Community system ❑ Private Rr Depth To Water Table 3.0--_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel E]. Sandy Loam ElClay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No ® New 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: rDistance from nearest well------I---------Distance from foundation___________________.Material______.____-_--___________------...._________-_-. <br /> ❑ No. of compartments---------------t----------Size......-------------------------Liquid depfih -------------------------Capacity--••--------------•--- <br /> F. ... . .. <br /> Disposal Field: Distance from nearest well-SIO----------Distance from founds+ion__/Q_"____.____-.Distance to nearest 1�g t linel............ <br /> ] Number of lines______,/__. _.--------------- .Length of each line_;__O-------------------Width of trench__�T_ .....__________--___-__ <br /> �--� ='De a-� - ry <br /> Type of filter materia pth offilter material.----�Q_-____----'-Total length---10__---_---•---------------------- <br /> Seepage Pit: Distance to nearest well------------------------ from foundation.__................Distance to nearest lot line____.-___________ <br /> ❑ Number of pits-----------•'----- ---Lining material-----.-----------------Size: Diameter-------•----------------Depth----..-.------------------------- <br /> r - <br /> Cesspool: Distance from nearest w0l_________________Distance from foundation___._.______.______.Lining material•_._________-- ___________-_---_-_ <br /> Size: Diameter. f - -------.Depth ---------------------------------------------Liquid Capacity--------••---•------------•-gals. <br /> Privy: Distance from nearest well jl---=----- ---------------------- ------------Distance from nearest building------------------------------------------ <br /> Cl Distance to nearest lot lii`e ----------------•----•----------------••--------------------------•---------------------- <br /> Remodelingand/or repairing (describe):-------- --- -------------------------------------------------------------------•----•-•-------....----------------••-----------•-•---•--------•------- <br /> -•-------------------------------------•-•---------.....-------••-------•----•-----...----------------•-------••------•--------------••------------------•----------------------------------------•---------------- ----------- <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, Stat laws, and rules and r gul ions of the San Joaquin Local Health District. <br /> (Signed)- --- --- --------------------------------------------------------------------••---.(Owner and/or ontractorl <br /> B -•-----------•• ------------------------------------------------------------ -------------------------------(Title)_.,_-_� _ _r_:_:-•=-- _ - .......--=-------- . . <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------ � �-----------------------------------------•---------- DATE.. `'� ' <br /> REVIEWEDBY--------------------------------------------- ----------------------------------------------------------- DATE-------------------------------.-_---•-------------------- <br /> BUILDINGPERMIT ISSUED_--------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations---- ------------- --------------------------------•--•-------------•--------- .....-------------••------------------•-----•----••---------•------------------- <br /> FINAL INSPECTION BY:./ tom._ ------------------------------- Date-_ .`a ------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Svreet 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 />