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FOR OFFICE USE: <br /> - - ... _- ................... <br /> ........ _ ._. ..__... ..... APPLICATION FOR SANITATION PERMIT Permit No. ......:_..:.... ..... <br /> .......-._.----......_............ --- (Complete in Duplicate) <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 described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION. ,' - _ f_< ._� � ; /✓am u•R i s <br /> /.. r r ✓ A, <br /> Owner's Name—...................... <br /> . ..--- ' <br /> �t s X2t1 - - --- -------...._._..................----------------....- Phone ••... -------... S. <br /> • <br /> Address...................-................ .._..-----...--------•- -...................--- <br /> Contractor's Name.....------------------ x:_ 4 -...-t............-- -----------­-­­ ------------- --. ...._............... Phone-----------......-•---...... <br /> Installation will serve: Residence (�r A brfment House ❑ Commercial E] Trailer Court ❑ Motel C] Other [I <br /> Number of living units: ...I.- Number of bedrooms - .. Number of baths ........ Lot size .........a...C;-..'..X...:3.3.:5........... <br /> Water Supply: Public system ❑ Community system ❑ Private IR Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam Clay ❑ AdobsIFIt 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: Distance from nearest well... 7f.(.--Distance fjorg fou�daton_......Zti7.-----Ma+eri�l.-._ - <br /> (y7( No. of compartments_--...... Z----__--.Size--_---�::.--f{. „�-Liquid depth_--.-..-�... Capacity_ A <br /> i <br /> Disposal Field: Distance from nearest welL...L.�L.'....Distance from foundation_.--r?QZ----Distance to nearest lot line....... <br /> Number of lines...-_.__.._ --------.........Length of each line---------------r7.0.........Width of trench. ' ---------------- <br /> Type of filter materiel..-srf:. ,-.-_..Depth of filter material......4F..........Total length.............fy..(--- <br /> /.._......_ <br /> Seepage Pit: Distance to nearest well......................Distance from foundation...................Distance to nearest lot line.......... <br /> ....-.. <br /> F1 Number of pits---._............._Lining materiaL......................Size: Diameter-..----------..-..----Depth................-_._....... <br /> ... <br /> Cesspool: Distance from nearest well.................Distance from foundation-----------. -----.Lining material..............................._.._.` <br /> El Size: Diameter--------......................Depth.--------......__---------- ......----'----..Liquid Capacity-----......----..........gals.1i <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 /> -----------------_........... ---------._-------------------...................---.................----..............---'..................---------------`-`---------------------------------------- <br /> I hereby certify that I have prepared this applicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, $# laws and�� ullee �ind,regu� ' ns of A San Joaquin Local Health District. <br /> (Signed)......- =.`.C_.C_Y--^::.`-::._ ..'.t .d.�l.L.�:./.�tl¢.:Z: -`....----...---'-----...------(Owner and/or Contractor] <br /> By: ......------.......-... --- .---!-.... -- - ----------------------------- file <br /> Y ) - - - - ..__.-... .._. .. ......._. <br /> (Plot plan, showing size of lot, location of system ,--elation to wells, buildings, etc-, can be placed on reverse side). <br /> FOR DEPAR ENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ...................-..... --. DATE--------22_—..*77_�C--l-----------._....- <br /> REVIEWED BY---------- ---------------............../. -........ -...... DATE.. - - ............................... <br /> BUILDING PERMIT ISSUED.............................................----------------------------------------------- DATE.----- -- ..........................-... <br /> --- <br /> Alterations and/or recommendations:...._........................---------------................-..-....--...---`_..............-.....-------------------.---------.--------_-------- <br /> 2 ,a".:r : .......................__....._........ ... <br /> ....-----..._.................. ------------............7-------...-...----. ..-......_. ................... <br /> FINAL INSPECTION BY:.-..,WA L1. _--- -- ------------ -- - Date.- ? ... ..�1 .........._. ..............- <br /> /SAN <br /> /SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street /300 West Oak Street 124 Symmore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Trocy, California <br /> ca a nw,em a ce r.n.ca.an•-eo <br />