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FOR OFFICE USE: " <br /> ' <br /> -- ---- APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------------ -------------------------------------- (Complete in Duplicate)This Permit Ex ires 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 LOCATI N---� - ---�� - - - -• ------0-,e <br /> ' ----------------------------------------------------------------.---------- <br /> Owners Name . . --••-- -------• •-----• -------------------- Phone---------------------.............. <br /> -.:. <br /> Address....... <br /> Contractor's Neme 1 ---------------------------------------------------------•-------­------ Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑// Motel ❑ Other ❑ <br /> Number of living units: J___ Number of bedrooms _f____ Number of baths __/.. Lot size ___________________________ <br /> Water Supply: Public system 0 Community system ❑ Private Wpo'obepth To Water Table IQft. �\�� <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe KII-fiardpan ❑ <br /> Previous Application Made: (If yes,date____________________) No 931� New Construction: Yes ❑' No [Tg­ 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 /> Se tij Tan), Distance from nearest well-----------------Distance from foundation--------------------Material____._____________.___________-____________-____. <br /> No. of compartments---------- •--------------Size--------------- •--......Liquid depth--------------------------capacity---•----•--•------••--- <br /> Dispos4l Fiel j: Distance from nearest wfel€__ ._._Distance from foundation.__,�r�____.____Distance to nearest lot line...to...._... <br /> Number of €ines---------- _ Length of each line______ _a f Width of trench._A._!f_______________________ <br /> i Jam/ 9 . <br /> �t �I i <br /> Type of filter material. .�/. Depth of filter material.___��__ .____Total length---------��____________ . <br /> T 'err` <br /> Seepage Pit: Distance to nearest well_____._c�0-____Distance fr m fo ndation_.- �.____..Distan;e to nearest lot line ________ <br /> �S Number of pits__----/-----._-----Lining mate rial__ �G _Size: Diameter-----�--__--_ Depth-----/0_ ________________ <br /> 3 kmp <br /> Cesspool:'"° Distance from :nearest well-----------------Distance from foundation__._----------------Lining material__._______..________.______._ <br /> ❑ Size: Diameter jE--------------------------------•-Depth----------------------------------------------------Liquid Capacity---------•--•---------------gals. <br /> FPriv Distance from nearest well-________________________________.____-___--_Distance from nearest building___-________-__-___--_•---_•-____..______- <br /> Distanceto nearest lot line------------- --------------- -----••----.._ -----••---------••-------•-•------•--- --------•-----• -----•-------- <br /> I F p <br /> Remodeling and/or repairing (describe)------------------- 414a------------ ----- ......... ........... ..........I............ <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 rulps and regulations f the San Joaquin Local Health District. <br /> {Signed}.. ------------ - r Contractor) <br /> -" _._Title <br /> (Plot plan, showing size of lot, location of system in rel to wells, buildings, etc., can be placed on reverse side). <br /> FO EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- --• - ---- - - ---------- ------------------------------ DATE-- __: -_ ------- <br /> REVIEWED BY-------------------_-•----•- ------------ ----------------------------------------------------------------------------- DATE------------------------------- <br /> -------------------------- <br /> BUILDINGPERMIT ISSUED..................... ----------------------------------------------------------------------- DXTE------------------------------------------------------------- <br /> Merations and/or re om endations___________ -----___ <br /> f la r <br /> 1 f �. _- <br /> ✓ - - - ---- -------- ------------------Y_, <br /> ............................. ------------------I-• --•---- --•---------------------•-------=•------------------------------------ .-..----• ----•----••---------------------------•----- <br /> -=---•---•--•-•-=--._....................................-'-----•--------------------------•----•------------•-•--•--------------------•--------•••_-. ...... -------------------------------------------------------- <br /> -------------------------------------------- <br /> I j <br /> FINAL INSPECTION BY:------ = .. = Date.------�1 = � — <br /> t <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street I 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lad[,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 zM 5-62 ATLAS <br />