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rUK Ut-FICE USE: <br /> --------------------------------------------------------- <br /> ------------------------------------------ --------------- APPLICATION FOR SANITATION PERMIT <br /> -------- ------- ------­----------------- Permit No. <br /> ------------------ - --- --------- ------ ------------ (Complete in Duplicate) <br /> This Permit Ex fres I Year FromDateissued 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 ..Aqr <br /> ............... ... <br /> .............. 2— <br /> ------- ---------- <br /> ------- ..... <br /> Owner's Name.__. <br /> ------M__ <br /> Address.. ------ Phone,p:°II.A :.O_ �a- <br /> Contractor's Name__�, �_ -------- <br /> --- -----------------------------------*---------------------------------------- <br /> -------------------------7----- -------------------------- -------- <br /> Installation will serve: ......•........ PhoneJ4A.. <br /> Residence 8--Xpartment House E] Commercial 0 Trailer Court E] Motel 13 Other El <br /> Number of living units: _1--- Number of bedrooms Number of baths ---e Lot size ___ "';' <br /> Water Supply: Public system-.-[] Community system 0 ...Qlve�:Z------------------...... <br /> Private [BDepth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam Rj'�Clay Loam El Clay [I Adobe 0 Hardpan <br /> ❑ <br /> Previous Application Made: (If yes,date----------------_--) No 2'_ New Construction: Yes 9--No El FHA/VA: Yes 0 No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi k: tante from nearest well----------------Distance from foundation--- <br /> -----------material <br /> 0. of compartments .................. <br /> 10 -------------Size ----------------- ..Liquid depth--- -4 <br /> Disposal Field: -----------------------capacity---------------- <br /> Id: Distance from nearest well---X 0 Distance from foundation.--_/-IQ- ." <br /> Number of lines_____.-------------I -------Distance to nearest lot line..,-<,^ <br /> ----------------------------Length of each line______ Width of trench___-- Z . . ............ <br /> Type of filter --Depth of filter material----J-1-----------Total length------ ---------------------- <br /> Seepage Pit: Distance to nearest well-----1-131- " ---�!---------------;W?------- <br /> --------Distance from foundation,----J_v........D�fance to nearest lot ljop S <br /> ---------- <br /> Number of Pits-----if----------------Lining material.._.0".-e*-----Size. Diarriefer-43.. . Depth_- ..... <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--_--------_----Lining material-------------------- <br /> Size: Diameter--------------------------------------Depth------------------------------ .....................Liquid Capacity....... --------I-----gals- <br /> Privy: Distance from nearest well ----------*---------- <br /> Cl Distance to nearest lot line Distance from nearest building-----•---------•----•--••--------------•-. <br /> -------------- -------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):---------------- �_Cl& -f— a.Ae&, <br /> - --------------------------------- -------------------------- -------------------- -------- -1.......................... <br /> ---------------------------------------------­----------­------I------------------------------------------------- ----------------------------- <br /> ---------------------­------------- V----- ---------------------------------------------------------------- <br /> ---------------------—,--------------------------------.......... ---------------------------­-------­--------I------I-------------------------------------------------- <br /> -------------------------------------------------I------------------------------------------- ---------------------------------------------------------------------------------------------------------------4 <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 /> --------------------------- (Owner and/or Contractor) <br /> r <br /> By:------ <br /> 11-7—----- ----------------- <br /> --------­-------- ----------- ------------------------------------------------------- ..... V <br /> {Plot plan, showing -----(Title ... <br /> relation <br /> f 10+, location of system in rela n to wells. buildings, etc., can be placed on reversedide). <br /> Fqlk DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- -------- <br /> REVIEWEDBY -- ---- ------------- ---------------------------- DATE-- <br /> -------------- <br /> BUILDINGDATE----- ----------------- <br /> PERMIT ISSUED. --------•- <br /> ----------- ---------------- <br /> ---_-------------------—--------- ---------------------------- DATE <br /> Alterations and/or recommendations:_--_____,--_------------------------------------------------------------------------------------------------ ----------------- -------------------­---------­------------------I------------------------------------------- <br /> --------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----I.....................I---------­---------------I--------------------- -----------------------------------------I--------------------------------------------------­-------------------------------------------- <br /> ------------------------I----------I....... ---------------------------------- ------- <br /> ---------- ----------*---------------------------------*------------- ---------**--------------------------*------------- <br /> FINAL INSPECTION BY:......... fZ4eft_ <br /> 5 <br /> ----------------- <br /> ------------ Date. ----- <br /> ---------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street <br /> es <br /> Stockton,California 205 W t 9th Street <br /> Lodi,California Manteca,California Tracy,C <br /> ra 9 REVISED B-59 2M 5.61 ATLA2 Calif <br />