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FOR OFFICE USE: <br /> -----------------__1--------------------------------------- <br /> -------------- <br /> �'- <br /> # --------------- -------_______ APPLICATION FOR SANITATION PERMIT Permit No. . s.. r S <br /> 4 <br /> (Complete in Duplicate) <br /> w Date Issued <br /> ----- ----------------------------------------- <br /> --- --- I 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 Ordinance �a na_KT <br /> /i 11-5 # <br /> JOB ADDRESS S 4LN.D LOCATION----- -- '- ` [_2 --------- ` ter` Q K <br /> 4 <br /> Owner's Na .;� - ----------- ------------------------------- -- - -------------------------------------- Phone--- ------------------------------- <br /> Address----------nw--- <br /> -------- <br /> z� J <br /> ------------------ - --- ---------------- <br /> Cont <br /> ----- <br /> Contactot <br /> l <br /> r`s Name---- ---- - -- ---- ------ <br /> --- ---A-------------------------------- Phone-=--------------------------------- : <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ ,Other ❑ " <br /> s, <br /> Number''of living units: -------- Number of bedrooms -------- Number of aths Sot size ________________________•�--_.__________________---- , <br /> Water Supply. Public system ❑ Community system ❑ Private Depth to Water.Table -- -_-_ ft. <br /> Character of soil to a depth of 3 feet:- S nd E] Gravel E] Sandy Loam E] Clay Loam flay E] Adobe El Hardpan ❑ <br /> Previous Application Made: (If yes,date.... _..f_,-----.--I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE,OF INSTALLATION AND SPECIFICAT10 S: <br /> t (No optic tank or cesspool permitted if public.-sewer is available within 200 feet.) <br /> Septic ank: Distance from triear�st well___ Q `Djstan e from foundation-----1.0___------.Material_____. <br /> Hy <br /> y No. of comps'rfr encs_:_` _ !f_Size_ +l_ „� -Liquid depth____ -.� _-. ------.Capacity__L_--- <br /> Dispos geld: Distance from nearest well._ . __Dt lot)ine___ <br /> istance from foundation-__.�_{T__.___._-Distance to neares �. <br /> Number of fines______._�r---------------------Length of each line_ _c_"' _ .....Width of trench.____. ______.--_ <br /> en _ <br /> Type of filter material_ --�_- Depth of filter rnateriaL_ _ ,� <br /> y �__11_�Total length____ y r- <br /> , g � _.-•---______________-._ r <br /> Seepa it: " Distance to nearest well---_1-�O---------Distance from foundation----1_f1..........Distance to nearest loft line--•.5.______-.- <br /> Number of pits.______`-______Lining material- --Size:Diameter___/ _ ._.._-__Depth____.� _�______________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------,_--------- .Lining material----------------------I---____.______- <br /> ❑ 1 Size: Diameter--------------------------------------Depth------------------ I------•------------ /---- --Liquid Capacity- ------------ ------------gals. <br /> Privy: Distance.from neares+ well----------------------------------------------I-Distance .from nearest building-:----_----------------------------------. : <br /> ❑ �. Distance to nearest lot line - --------------­.— <br /> .---- <br /> - G <br /> Remodeling and/or repairing (describe= !- 7 <br /> 1------------•----------------••--•--•------- + # t <br /> ri <br /> x <br /> -------------------4:y--------- ---------------------—---p-----•-----• ----pp-------.----- ------------------------------:--•--- :- -= <br /> f F r. j <br /> I hereb certifythat I have prepared this application and that the work will be,done to accordance with San Joaquin.County <br /> ordinances, St ws, and rules ad regulations of a San Joaquin cal ealth District. i <br /> a ---- ; _ <br /> (Signed) --- - -- a------ /�--------------- rn---_^_ _-�/or Contractor) ` <br /> C <br /> (T sy:-- -------`�•-�=�3 --- -- - `- (Title) `----- ----- - - _ <br /> (Piot plan, showing size of lot, location of system in relation to ells, ui ings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> -APPLICATION ACCEPTED BY-- --------------------------------------------------------- DATE-- <br /> REVIEWEDBY ------------------------------------------------------------------- DATE---------------------------- <br /> - ---------------------------- <br /> BUILDING PERMIT ISSUED------•--------------- ------------------------------------------------------- ---------------- DATE------------------------+ r <br /> Alterations and/or recommendations:---------------------.------- <br /> ----------------------- - -------------------------------------------------------------------- ---------------------------•------------------------•-- ---------------------------------------•---------------- <br /> 1 <br /> -------------------------------------- - -------------------------------------------------------------------------------- -----------------------------•----------------------------------------------------------- <br /> ---------- --------------------- - - ........ --------------------------------------------•---------- -----------------------•--•------ -•---------I---------- ------------------------------------------------------ <br /> FINAL <br /> ----------------------------------------------------FINAL INSPECTION <br /> BYA,- -; _��-: <br /> -- <br /> - - ----------------------------------- <br /> 1 a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 3M 3•'63 F.P.QO. <br /> i <br />