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APPLICATION .FOR SANITATION PERMIT Permit No. .. 1 -5.. s <br /> (Complete in Duplicate) <br /> This Permit Expires 1 Year From Date Issued Data issued _______ <br /> SZ -r . . a. <br /> Application,is hereby made to-tfie San Joaquin-LocakHi alfh District for a permit to,construct and.install the work herein described. <br /> This application is made in compliance with Coup V <br /> JOB ADDRESS AND LOCATION--------•------ ---------------------------------- ----r ' - ' <br /> Owner's Name-------- --------- -------------------------------------- Phone <br /> Address ' o= /sr� 1 �'''?9 '� - ' r <br /> Contractor's Name. `' :: -------------------------------------------------- Phone------------------_------•------- <br /> Installation Ji I serve: Residence Apartmenf"�House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> # ,. - <br /> Number of living units: _if—Number�o bedroos __ ___ Number of baths __,�-- Lot size <br /> Water Supply: Public system� T Community system ❑ Private L3•- Depth to Water°Table -------- ft. "-` <br /> Character of soil to a depth'-of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loan p Clay ❑ Adobe'[ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No � New ConstructioA Yes [' No ❑ FH FHA VA: Yes E] No E4 <br /> TYPE OF INSTALLATION ANDSPECIFICATIONS: """'"""" <br /> (No septic tank or ce;spo.iol permitted if public sewer is availa'bl'e within 200 feet.) tr <br /> Septi Tank: Distance from nearest wel ------- Distance froml foun`daation____ <br /> No. of compartments----- -----Size___ -4 - ' -7---Liquid depth_____ Capacity__.__-r �''� <br /> Disp sal Field:! Distance from nearest well. -._._.._`"'Distance f��f�o atn___ __---Distance to nearest lot line___Jr-_..... <br /> Length of.eacl��f?ne�------- �-�__---Width of trench------�---------------------- <br /> Number of Eines------------ - ---- ----- g <br /> Type of,fil{ter mate rial_./?-4*<c'+....Depth of foe. material__ 1_ �i Total length____-•�_��____________________._ <br /> 4 ----------- <br /> Seepage Pit: Distance7to nearest well--------------t------Distance fro' foundation-------------)-----.Distance to nearest lot line_____________.-. <br /> �] Number of pits-�-----i- Lining}material. Size: DiamefAr------------- DeI5fh--------------------------------- <br /> ----------- <br /> foundation------------f_ Linin material-�---------------------------------- <br /> Cesspool: Distance f}rpomnearest Zell----------------- from' ----- 9 .. <br /> ❑ Size: Dim Rter------------ -- Depth------------i--------------- �---------- -� Liquid Capacity---------------------- <br /> Privy <br /> � ------gals. <br /> Privy: Distance from nearest well-____.._ __________________________ ___Distance from' nearest building___ , <br /> ❑ Distance to nearest lot line------I---------------------------------I <br /> ------•-----------—-----i-----•------------------------c--- --------------- --------------- <br /> �. <br /> Remodi, and/or repa€ring Idescrsbe):---- - --------------------------- ----------------------- ----------------------------•----�--------------- <br /> ----------•----------#•------------------------•--- -•------ ----------------------- -------------------------- ------ ------------------------ . -------------=----------------:=------------------------------- ------ <br /> -------------------- --------- ------------------------------ ---------------------------= ---------------------- { <br /> I hereby ati <br /> certify that I havi prepared this appiicon-and�ha f e�work will 6e done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and-.regulations of the San Joaquin Local Health District. <br /> ---------- -- ---------- <br /> ---�- t ---------------i----------------------.(Owner and/or Contractor) <br /> (Signed} <br /> Br ---------------------------------- ------------------- -;' ---------------------.------(Title)-- --------------------- ---... _---------------- <br />'E (Plot plan, showing size of lot, Iication of system in relation to wells, buildings, etc., can be placed on reverse side). s <br /> I. ( FOR fJI:PARTMENT USE ONLY <br /> t?I -------------------------------------- DATE---- -{ t ----------------------- <br /> Xr—APPLICATION ACCEPTED BY__.____ ,rte <br /> REVIEWEDBY == �'". = r------------ -- - i=-------------------------------------------- DATE-- --- ----------=-=--------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------- DATE- -------- ----------------------- <br /> Alterations <br /> ------ -------------- <br /> Alterations and/or recommendations---------------------------- — <br /> ------------------------- -----•------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------- <br /> -----•---- ------------------------------------------•-----------------------------------------------•------------------------------------------------------------------------------------------------------------------- <br /> ----------- <br /> ---------- -- --- <br /> j ------•-----------------------------------------------------------------------•-------------------------------------------------------------------- ------ ---------------------------- <br /> --------------------------------------- <br /> FINAL INSPECTION BY:---Q......ilettl-{..r-------- ------------------------- Date------ -- - -------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 30D West Oak Street 132 Sycamore Street 814 1`Ncrth "C" Street <br /> I Stockton, California Lodi, California Manteca, California Tracy,-California <br /> i <br /> ES-9-2M Revised 8-'59 F,P,Cc. I <br /> 1 <br />