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FOR OFFICE U 1' <br /> = � <br /> _--..--.- ------------------------------ APPLICATION FOR' SANITATION PERMIT Permit No. <br /> ----------------------------­­-------- -- ----- (Complete in Duplicate) <br /> Date Issued ._.__ 117_.d Z <br /> ____________________________________________ This Permit Expires 1 Year From 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 Ordina No. 549. <br /> JOB ADDRESS AND LOTION----•-- p + -� ----------------................. -------------------------- I <br /> Owner's Name------------ - ------- Cl _---_-------------•---------------------------------•----•--------•--------------------- Phone. <br /> Address-------------------•-•......•..-----------.... .. ------ <br /> ---------- <br /> �' A : Phan / <br /> ._s�. <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel T Other ❑ <br /> Number of living units: I------ Number of bedrooms _��_ Number of baths /---- Lot size _11-17....... ----------__ s <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ........ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeO Hardpan ❑ <br /> Previous Application Made: (If yes,date-----_--------_-----) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ j <br /> OF INSTALLATION AND SPECIFICATIONS: 1 <br /> (No septic tank or cesspool permitted if public sewer is available within 244 feet.) <br /> 1 <br /> ptic T nk: Distance from nearest well_________________Distance from foundation--------------------Material------........................................... <br /> No. of compartments-------------------�----Size---------------------------.---Liquid de t--------------------------Capacity---.................. <br /> pas Id: Distance from nearest wel _ ____Distance from foundation_ __....Distance to nearest lot line.__....... <br /> Number of lines•-._�._.__. . .._. ______ Length of each Iine .I - ____ _ ____.Width of trench.___�.5e.111__--•----__---- <br /> dType of filter material. Depth of filter material------2 _______Total kength. Q.P ----•---•/----- _. <br /> Seepage Pit: Distance to nearest weIL�O0________Distance from oundation__�.�.......___-Di Lance to nearest lot liy-____6__--_-- , <br /> Number of its..... Linin material__&c. _ Size: Diameter---. _ _.... <br /> _________________ <br /> Cesspool: Distance from nearest well.................Distance from oundation___________--_---.Lining material.._-................................. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------•-•----------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___________________-•__•-_-_____-_---_.--. <br /> ❑ Distance to nearest lot line.------- •----------------------------•----------_--------'---------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe) ---------- -------------------------------------------------- •---------q----------- -------------------.------•--------•---•---- <br /> -----------------------------•---------------------•-•----•-....... ---- •---- -------- - <br /> I hereb if t I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordina e ! wt;,, d rules and r g lations .f the San Joaquin Loc alth District. <br /> EV(Signed) t = Contractor) <br /> By:.....--------------------------------------------------------------------------------------------- =-t- --/.----(Title}--------------------------••-------------------- -------------- <br /> (Plot plan, showing size of lot, location of system in relation to w , buildingcan be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- - ---------- -------------------------------------------- DATE---- 9 Ufa 2--------------- <br /> REVIEWEDBY----------------------------------------- - ------------------------------------------------------------------------------- DATE----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------•----------------------------------------------------------- DATE-------------------------------------------------------------- <br /> Alterations and/or reconyrien,crofions:_•-----------&4--------------------------------- ------- <br /> FINAL INSPECTION BY:....J.. _ Date---¢.__ _. 6 <br /> . f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> EE 9 REVISED 8-89 ZM D-41 ATLAS - J� <br /> 1 <br />