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FOR OFFICE USE: A <br /> ------------------------------------------ -------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ---------------------------------------------------------- (Comple4,'in Duplicate) <br /> ------------------- - <br /> ------------------------------------- 'This Permit Expires 11"Year-From•Date Issued Date-Issued R/01111� <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 ' Ii ati?njs made in complianc?eifCounty Ordinance No. 549. (0 1-3 -2--e 0 <br /> V,0 <br /> J <br /> OB ZDRESSAN LOCATION______ ------ ------ <br /> -------- -- -------Of ---I -------- ---------- <br /> Owner's Name.26 kwcle �Azk_ rl1----------- hone---,,---­------------------------ <br /> Address-----F" ............. --- <br /> ------- ---------------------------------------------------------------------- <br /> ------------ ----- <br /> Contractor's Name---- ---- - -- --- ------------- ----------------- Phone ----------- <br /> ---- ---- --- ----------- --------- <br /> Installation will serve: Resiclenc�epartment House [-] Commercial E] Trailer Court [] Motel El Oherd. El <br /> Number of living units: ---/--- Number of bedrooms 07-- Numb baths�_ Lot size ------------ <br /> Wafer Supply: Public,system El Community system El Private ��Depth Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy Loam C lay Loam E] Clay E] Adobe❑ Hardpan E] <br /> Previous Application Made: (if yes,date------ --------) No Ej New Construction: Yes [-] No 0 FHA/VA: Yes 0 No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> 'Septic Tank: Disitance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------ <br /> ❑ No. of compartments-------------------- ----Size--------------------------- -..Liquid depth-----------------------7777-Capacify---------------------- <br /> Disposa field: Distance from nearest well-- Distance from foundation------/_0--------Distance to nearest lot line------S------ <br /> Length of each line-------1-0-Q_--_-- --------Width of french---- <br /> Number of lines--------------/-_ ;1------------ V1 <br /> Type of filter maferial__��-----Depth of filter material-------/,f-------Total length----_-1 ------------------------- <br /> Seepage Pit; Distance to nearest well--------------- Distance from foundation---_-_--.---..--_--Distance to nearest lot line--------------- <br /> D Number of pits----------------------Lining material---------- ------------Size: Diameter=------ Depth-.------------------------------- ' <br /> Cesspool- <br /> epth--------------------------------- <br /> Cesspool- Distance from nearest well-----------------Distance from foundation____- - -------- Lining material---_-__------.----.---.---_------__ <br /> ❑ <br /> aterial------------------------------------- <br /> F1 Size: Diameter----- ----- ------ ------- -----------Depth----------------------------------------------------Liquid Capacity----------------------------gals <br /> Privy: Disfance.from nearest well------------------------------ --------------------Distance from nearest building----------------------------- <br /> ------ <br /> ---- <br /> Distance to nearest lot line----------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):--------- ----------------------- ---------------------------------------------------------------------------------------------------------------------- <br /> ------------------------•.1------ II--------------------------------I----------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------*---------------------------------------------------1-11,--------I------------------------------I--------------1-1---------------- <br /> -----------I----------•------•------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <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 s, rules,.anpegui ti.ons the San Joaqui VAocal Health District. <br /> (Signed)------------------------- --------V ..... ---------------------------------------------------------------------- --4fl�� /or Contractors a`14��_ Oi j � <br /> By:--------------- — ------ - ---- ---- ------ ------ Ifle)-_ -------- -PXCW <br /> ----------- ------------ ------ ----- ---------------(Title} ----- -------..................... <br /> - ------- -- <br /> (Plot plan, showing size of lot, location of system in relation to w2s, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> ------------------------- ---------------------------------------- DATE----- <br /> REVIEWEDBY------------------------------------------- ----------------------------------------•------------------------------------­ DATE--------__--------------------------------------- <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------—------------------------_----------- DATE------------------------ -------------------- --------------- <br /> Alterationsand/or recommendations:------- -------------------------- --------------------------------------------------------------------_----------------------------------------------------- <br /> , I <br /> -------------I---I-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------- ---------------------------------- -------------------------------------------I----------------------------------------------------------------------------------------------- <br /> ----------------- ---------------------- --------------------------------- ----------------------------------- ----------------------------------------------------------------------------------------------------:--------- <br /> -------------- ----------------------:----------------------------------- ------------------------------------ - ----- <br /> FINAL 'INSPECTION BY:---- ---- ---- ---------- Date.... ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Maxeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lad!,California Manteca,California Tracy,California <br /> ES 9 REVISED 8-59 3M 3-63 F.P.120. <br />