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FOR OFFICE USE: <br /> ------•------•.....:............ ............. _ <br /> ..................... ....._.._.__....--__ APPLICATION FOR SANITATION PERMIT Permit No. ...Z-7,l....... <br /> ........................................ •-------_- (Complete in Duplicate) 4.y <br /> -� ---------- - --- ••------•-----.•--..---- ----.... This Permit Ex ires 1 Year From Date Issued (Z�(apy <br /> Application is herebymade to the San -----. - <br /> Joaquin Local Health District for a permit to construct and install the work herein d scribed. <br /> This application is made in compliance with County Ordinance No. 549. v �j <br /> JOB ADDRESS AND LOCATION„. <br /> -�'�° <br /> ----- - <br /> -•- <br /> ----- <br /> Owner's Name. ------ Phone---- ............................. <br /> Address------------- <br /> -�.I _._.. <br /> 41 <br /> Contractor's Name ---- - - ------ --- _---------_------------- •--•----• ---------------------- Phone----- <br /> --- - ---•----------- <br /> --- ---- ---- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Tra;;IErr urt ❑ Motel ❑ Other , <br /> Number of living units: -------- Number of bedrooms ------- Number of bathe of Size -_3 .....Qiu- ----------------- ... ..._ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table/�: ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (!f yes,date. .... .__._ ) No ❑ New Construction: Yes ❑ NoX FHA/VA: Yes ❑ No ❑ <br /> l <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: � <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 8 <br /> Se tic Tank: Distance from nearest well------- . Distance from foundation-------------------- ...................... t� <br /> No. of compartments--. .......... Size-------------------------------Liquid depth----------- ----_-_---Capacity....................... N <br /> Feld: 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 filter material----------------------- length___--------------:.___.______._________..- <br /> 7 <br /> Seepa e Pit: Distance to nearest well._./_.-.5-... _._..Distanc rom oundation.. -_...D,istance to nearest lot line_..S.r...... <br /> Number of pits__./_.............Lining`material_. ....Size: Diameter._5X?1___!"Depth-- <br /> Number <br /> Cesspool: Distance from nearest well...............--Distance from foundation---.................Lining material._..__.--.-..-----..__------___..__.- <br /> ❑ Size: Diameter.•--...•---------------------------t.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 /> _...-•---•-••-•--•----•-•-•-•-----•-•-----•................•-••--...----........---------­-----......--•----------••-......-------••---.......................................................... ............. <br /> •----------------------------------------- <br /> I hereby •fy that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, S ate aws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)----...- - ( ner and/or Contractor) <br /> B ..(Title)------- --- -!•-----------------_------ ---•-•-------- <br /> _:-_ — <br /> ...---•---------------------•-......------....-----••• ---- ---'- -I <br /> (Plot plan, showing size of loft, location of system in relation to wells, bui Ings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.......1..L -.qf----------------- ----------------------------------------------------- DATE_ . .. ..... 9.1 <br /> REVIEWEDBY................................... ..................•--•------------- ----------------------------------------------------- DATE_1.........•--_...._...... --_--_-•----•---•--- <br /> BUILDINGPERMIT ISSUED___......................`�-,. �- ............................... DATE DATE... .................................. <br /> Alterationsand/or recommendations ................................ ------•---.-..-•------------------------------•--..................................................................... <br /> ....................................... .....................-.....---....... -- .... i.................. �..... <br /> ........... ---•----------••--•-•....................••--•--.._..............---..... ........--.............................................................................................................._.......... <br /> c ....................................••-----•. <br /> FINAL INSPECTt N BY - - Date......... ..- <br /> ......................................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 0-59 3M 3-'63 F.P.CD. <br />