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FOR OFFICE USE: <br /> --- - -- --- ---- ----- /S S.f <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 cons herein described. <br /> This application is made in compliance with County Ordinance No. 549. � �J)k <br /> 6,7h'7 XE7. • , f. .� <br /> JOB ADDRESS AND LOCATION AClr y - ----�XAZ ------- _' '"'! ------------ ------- <br /> Owners Name. Phone-------------------------------•---- <br /> Address............... 3 <br /> Contractor's Name........lV__#$--3,--- -------- ------ --------------------------------------------- Phone..............m.................... <br /> Installation will serve: Residence g) Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: J..... Number of bedrooms Number of baths __I.... Lot size ...��-Qtflltib--_----•___-•______________________ <br /> Water Supply: Public system ❑ Community system ❑ Private gj Depth To Water Table 7_Q__ ft. <br /> Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam ❑ Clay Loam RI Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: llf yes,date--------------------) No New Construction: Yes ;0 No ❑ FHA/VA: Yes ❑ No ❑ J <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi Tom: Distance from nearest well_________________Distance from foundation--------___________.Material__------_------.___-__________-_______.__.._-... <br /> /✓_ No. of compartments------------- ------------Size---------------------------- --Liquid depth--------------------------Capacity.........-........ <br /> ..... <br /> Isposal Field: Distance from nearest well...s�__0_'f----Distance from foundation___LD_!______Distance to nearest lot line_*S��___..... <br /> Number of lines........1---------------- <br /> 4-_ .-Length of each line..../_0 ___-__-_---_-_-_.Width of trench--Ay-,4 ....._--______._...__ <br /> Type of filter materia �___P__._______Depth of filter material___11y..__--_-._-Total <br /> Seepage Pit: Distance to nearest weir---------------------Distance from foundation--------------------Distance to nearest lot line____.___.___..__. <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-m----------_------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------_--_--__•__--___- <br /> ❑ Size: Diameter---------------------- -•------------.Depth_--------------------------- ---------------------Liquid '4Capacity-----------••------.........gals. <br /> Privy: Distance from nearest well-----------___------------------------------------Distance from nearest build in9--------------_------------- <br /> ___________._. <br /> ❑ Distance to nearest lot line-----------------------•--------------;----- --------------------- -------------------� n ([� <br /> Remodeling and/or repairing (describe):--------------•----------------•-___----------..: r i•----------- --------•--------------------•-•-•------------------------------• `I ' <br /> f <br /> .......«_____-----------------_--------------------------------------------------------------------------_-------__ __-___-----_--•_____-_-____--______--__.._-______..________-»____-__...-.__-_.____.___________________ <br /> -------_---------------- <br /> ------ �- <br /> _____________________________«.____.._______-._____________.;________-______________________________-_-___-______________________________________________________-.-________-_-_-________-____________________._.__.____._-_. <br /> I 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 the San Joaquin Local Health District. <br /> (Signed)-------- A,__ --- 'Y'lC/ (Owner and/or Contractor) <br /> By:--------------------------------------------- --------------------------------------------------------------------------------(Title)---••---•---•---•--------------------------- ---------------- <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 •7 <br /> APPLICATION ACCEPTED BY_ --- ---------------------------------------------------------- DATE... { �a 3------------•------------------- <br /> REVIEWEDBY--------------------------------------------- -----------------------------------------------•------------ DATE--------------------------------------------- <br /> *.......... <br /> .. <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------_ DATE------------------------------- <br /> ----------------------- <br /> .. <br /> Alterationsand/or recommendations----------------------------- --------------------------•---------------------------------------...------•----••--------------•-------•-------------------.-- <br /> ------------------------------------------------------•------------------ -- -------- ----------------------------------------------------------------------.................----------------------------------------------- <br /> ------------­ <br /> -•---- <br /> ---•-•-•----...----•------------------------------------------ ------- ------------------------------- --------------•-------------------------------------------------------------------------------------._... ----. <br /> ----------------------- ------------------------------- ----•---------------------•------•-----------------•-----I-------------------------------------------------•-- ------------------------------------- <br /> FINAL INSPECTION BY Date T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strut 300 West Oak Strut 124 Sycamore Street 205 West 9th Strut <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED 8-59 2M 5-62 ATLAS <br />