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1 W / <br /> y APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> App{i`tion 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 1County Ordinance <br /> Wap 1 <br /> ffOB ADDRESS AN OG TIO ... ------------------- ----- --- <br /> Owner's Nam -- _ _-- ,„-� /, -____-- - Phone._ r/ <br /> x Address , -----•----- ------- <br /> I_ <br /> Contractor's . - - r---- - - ---- -- .--- ---- t-------- h ne. ----2, <br /> Name------- ti _ Phone. _ _ <br /> 1. <br /> Installation will serve: Residence Apa ment (Ho susu a ❑/ Commercial ❑ 'Tra er Court ❑ Motel Cher ❑ k <br /> Number of living units: ---�- Numbler of bedrooms __f_--- Number of baths ----1_- Lot size _ a__ %_ .(J-------------------- <br /> Water Supply: Public system Community system [-] Private E] ��_ <br /> Depth to Water Table `�ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobaX Hardpan ❑ <br /> Previous Application Made: Yes ❑ Na New Construction: Yessx No ❑ FHA/VA: Yes ❑ NOA <br /> 1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:' 4 <br /> t (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) <br /> ptic 11, <br /> Tafl k. Distance from nearest well-.-----I---------Distance from foundation------------------ Material------------------------------_--___-------_---. <br /> - No. of compartments-_------- ---------Size--------------------------------Liquid depth--------------------------Capacity---2�-_ <br /> I <br /> Disposal d: Distance from nearest' well___._.----------Distance from foundation--------------------Distance to nearest lot line--__-__-----..-.. <br /> Number of Dines--------- --------------------- Length of each line------------------------------Width of trench-----------------------------____-- <br /> Type of filter material--------------- ----- --Deptli of filter ma#erial-----------------------Total length----:------------------------------------- <br /> See a Pit: Dis#ante to nearest we Distance from fo dation__ ' <br /> - ,�� -_._..D.istance.to,nearest lot line.-_,�..____- <br /> �� Number of pits----- ----------Lining materia <br /> Cesspool: <br /> Diameter_____ - _ Depth___, _--__________._ (� <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-_._-______________._______._________. <br /> Size: Diameter------------------------- De --------------------------­­----------------------Liuid Capacity- gals. <br /> ­`Privy❑:. Distance from nearest well-------------------------------------------------Distance from nearest building----,_.._.____._._.______�f._______.___. <br /> Distanceto nearest lot line------------- ------------------------------ ------------------------ ---------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):_I <br /> -- - - - --- ------- <br /> f. ----------------------------------F ---------- = ---------------------------- ------------------------ <br /> I .1� <br /> _ ----------- --•----------------- ---------•--------------------------------------- ------ ----- -- <br /> " - = <br /> ---------- -------- --------------------------- - ---- --- -- <br /> --- -- ------- ---------------------------------- -- <br /> I hereby certify that I have pre `red this applice ' n an haf the work will be done in accordance with San Joaquin County <br /> ordinances a la and ru ar egulat' sof a Sa oaquin Loc l Ith District. <br /> r <br /> (Signed). = I =:! G (Owner nd/or Contractor) <br /> BY�-t `------------------------------------------------------------------------------- (Title.) Y -------------------------- <br /> (Plot plan, sho i g size of o , location of system in relation to wells, buildings. etc., can be p aced on revers ide). <br /> j FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---'---- DATE--------------------------------- l <br /> REVIEWED BY--------------------------------- ------ DATE--- -'l L <br /> BUILDING PERMIT ISSUED------------------ <br /> ---------------------------------------------------------- DATE ;` 1 ----------------------------- <br /> Alterations and/or recommendations:------ ;` -----P--- ---------------------- -----------------•-----------------------------•---- --------------------------------------------- <br /> ---•-------------------------------•----------r------------•--------- - -------`-- ------------------------------_- ----------------------------------------------------•-----------------------------•-------------- <br /> - ------------------------------------------------------------------------------------------------- <br /> ------I---- - <br /> - t <br /> ----------- <br /> ------------------------------------------------- -------- :---------------------- --- ------------ ------- - -------- -------------•--------------------------:----- ---------------------------------------------------------------- <br /> FINAL INSPECTION BY:---- _--- ------ ------------- Date-.----- -.-...._-_.-- _ <br /> -- -------- -------- - - --------------------------------------------- <br /> - <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised 1-57 F.P.CO. <br />