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R QFFICE USE: r - - <br /> __ __---_-------____________r- R �. <br />_________ . _ _ _______ APPLICATION `'FOIA SANITATION PERMIT Permit No. ....................... <br />------------ ---- r:-- ---- --------------- (Complete in Duplicatelr/ <br /> ------------------- 'This Permit Expires 1.Year From Date Issued Date'Issued . %l,___ _ 7 <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 rdinance No. 549. <br /> JOB ADDRESS ;� D LOCATIO ..... __, -F ---------------------------------------------------------------------------------------------- <br /> - --- - <br /> Owner's Name---- --- - -- ----�-----------•-------------•--------------•----------------------_-------------------------------------------- Phone_----------•------------------------ <br /> Address. l 1 —................•-------------------------------------------------•---------------------------------------------------------------------------------- <br /> Contractor's Name-------- am______________ <br /> ---••------------------- - - - ----------------------------------------•--. Phone----....-------•-------••--------- <br /> Installation will serve: Residence Apartment House C-] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> 73't. i <br /> Number of living units: _1.___ Number of bedrooms _-:3... Number of baths.- -____ Losize ------- -___________________ <br /> Water Supply: Public..system [!�_Community system ❑ Private ❑ Depth to Water Table _46�t. <br /> Character of soil to a depth of 3 feet. ,Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2-14ardpan (❑ <br /> Previous Application Made: (If yes,date____ _________ _____) No [; New Construction: Yes Uj'TNio E] FHA/VA: Yes Pq--_NO ElTYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) I - <br /> Septic Tank:- Distance from nearest w Il_f___..___Distance from foundation_jA_ _-___.___.Ma'eriaL__I --------------- <br /> [ No. of compartments--- ----------------rySize---3_X__}—X---`7'._-__-__-Liquid depth---/_______...__...___Capacity-- Qa'�- <br /> Disposal Field: Distance from nearest well-_..._:_._.-----Distance from foundation-_t�.............Distance to nearest lot line_________________ <br /> Number of lines____________________---_`_Length of.-each line._/ _`___S=p_ _._.Width of trench.__ '_._________-_-- <br /> ..Type.of filter material__-_ _Ck- :__..__Depth of filter material___)fr_`__-----_--Total length_._J„S"4- '___ <br /> J' <br /> Seepage Pit: Distance to nearest well._.."_____-.-_--Distance from foundation---/O__r________-Distance to nearest lot line-S_--------- /� <br /> ![� <br /> Number of pits._._-------------Lining material---____- bG t--Size: Diameter__._..3�`_._._____Depth--_-.2_ ------------------------ <br /> _'__________..___1 00 <br /> Cesspool: Distance from nearest well_________________Distance from foundation---__._______ Y__lining material------------------------- <br /> __________.. <br /> r <br /> ElSize: 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):----------------- --- -------------------------------------------------------•---------------------------------------------•--------------•---------� <br /> --------------•---•--------------------------------------- -------------------------------------------------------------------------------------------------------- ---- <br /> ------------------------_------------_M1________________.__________________--____________-__________________-______________________________-_________________________-_---__-9r_______.___________.______-__________,._--_.____ <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 the Sa Joaquin Local Health District. <br /> 4 ' <br /> •------------------------------------------- ----- --- .(Owner and/or Contractor) <br /> (Signed)------------------------ <br /> BY: °------------------------ ------- - ---- ------ ----------------- -----------------------------------------(Title)-------------------------- ----- - ---- --------------- <br /> (Plot plan, showing size of.lot, location o system in relation t wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- f ----------------- --------------------------------------- DATE--- '3- `Gr <br /> ----------------------- <br /> REVIEWEDBY - --- ------------------------------------------------------------------------- DATE---------------------------------------------------•------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------- ------------ DATE__e------------------------------------------ -------------- <br /> Alterations and/or recbm_Men ations______________.___.._____ . -M <br /> ___________________;......._.�-___._______�_ - _..___-._..____.._____ <br /> r- <br /> f <br /> f --------- <br /> ---------------------------------------------------- ------------ - --- - ---- -- --------------------------------------------------------------------_---------- - ---------------------. ------- <br /> FINAL INSPECTION BY:.---------�,: � �`3--------------------------- Date 3--------------(� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 V REVISER U-59 3M 3-'63 F.P.CO. <br />