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v1 APPLICATION FOR SANITATION PERMIT Permit No,.§___!� <br /> (Complete in Duplicate) Date Issued <br /> V ____"�__._-----_ <br /> t Applica+ion 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 AN LO0 <br /> &AT10 ._______ <br /> p� 969 <br /> Owner s Name---.t L_ : -------•---- �' Phone <br /> _ _________.. k <br /> Address---------- = .... =--------------------- <br /> - <br /> / �J <br /> Contractor's Name__. - "9✓�4 tl 4 --------------•--- Phones! ---�-1-r�- <br /> Installation will serve:. (Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of Living units: Number of bedrooms -c.2— - Number of baths ---C__ Lot size __I-7..Q - Q -------------------------- <br /> �. Water Supply: 'Public system ❑ Community system ❑ Private [Depth to Water Table _v� ft. { <br /> Characfer of soil to a depth of 3 feet: ,Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ff-'/Hardp-an ❑ v <br /> • <br /> Previous a Application Made: Yes ❑ No [ii/ New Construction: Yes [?""No ❑ <br /> S <br /> 3 TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Distancg from found -- <br /> — _O__ <br /> __Septiank: Distance from neare �Q _ Material0 - t_ <br /> No. of compartments--- ----: - -----SizeQ.. Liquid depth------4"3............-Capacity./ <br /> i <br /> Disposal Field. Distance-from nearest "f ell_,Fd..._ �'__ _Distance from foundation__s��__.__----Distance to nearest lot line.---f�_______ <br /> umber of lines__ __ L_ _ Length of each line____._Io�Q- _________.Width of trench--_-_�_------_'__________ <br /> i y,-- ��. _ ...r j .. <br /> ���Type of filter materially_' of filter material_-_--_I ________Total length_____...1 _______ __________ f`T <br /> Seepage Pit: Distance-to nearest well----------------------Distance from foundation------_.-_...........Distance to nearest lot line--__.---________- <br /> , ❑ Number of,`pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> } Cesspool: Distance from nearest well----. -----------Distance from foundation_------------------Lining material------------------______________-____ <br /> ❑ Size. Diameter--------tl------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. <br /> Privy:. Distance from nearest yell---------------------- --------------------------Distance from nearest building------------------------------------ <br /> ❑ R Distance to nearest lot line--------=--------------- -------------------------- --------------------- <br /> , <br /> Remodeling and/or repairing (describe)-------------------------------------------11­1-------I----­---------------------- -•--•----------------------------------------------------------------- <br /> � <br /> -------------------------- ------------------------------------ --------------------------•• ----------------------•-•--------I-•-•--------------------•-------------------------•------------. ..- <br /> i <br /> i -------------------------------------i------------------- <br /> '-----------------------------------------------------------------------------------------------------------------------------------------.----------------- <br /> I hereby certify that-! have prepared this application and that +he 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)--------------- ---- ----- i *''-� <br /> ----------------------------------------.-------------- --------- and/or Contractor) <br /> B �'`� --(Title)----(�R.�� -- --------------- <br /> Plot Ian, showing size of.lot, location of system in relation - -- --'ells_ _______________________ <br /> ( P g y ion to wells, buildings, etc., can be placed on reverse side). <br /> S <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = f } N------------------------------------- DATE--__0 - 4 -- ------•----------------- <br /> REVIEWEDBY----------------------------- ------------- ------------------------------ -----------------------• ........ DATE------------------------------------------------.....-.---- <br /> BUILDINGPERMIT ISSUED-------------------=------- --------------I--------------------------------------------------------- DATE------------------------------------------------------------ <br /> Alterationsand/or_recommendafions--------------------------------------------------------------------------------------------------•---------------------------------------------------------------- <br /> ----------i----------------------------------------- ------------------------------------------------------ ---------------••--------•-•----------------------------- ........__...,---------------------------------------- <br /> ---------- <br /> R <br /> ___..___'____----------------- <br /> -----------------------______---------------- <br /> -----------_--------------------------- <br /> -----F------------------ <br /> ------------------------.---------------------------------------------------------------------------------------------------------- <br /> ----------------------._______.___._______-----._---_-_._-__--___.-____________.____-__. <br /> 1 t . <br /> �/ , <br /> FINAL INSPECTION BY------------------fl.---g � : /1'l�. Date_ - = -=F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfree+ F 814 North "C-Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ' Revised W-2100 <br />