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FOR OFFICE USE: Zp q 3 v 2 0 `tet <br /> ---- - ----- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ....l Y--.::z 5... <br /> -------------- (Complete in Duplicate) Alk, <br /> 6 <br /> -----------------_------------_------_-----_______________ This Permit Expires 1 Year From Date Issued <br /> Date Issued .--cp-l. �.C <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 compliant with County Ordinance No. 549. <br /> JOB ADDRESS ANDCATI .� ................ <br /> Owner's Name ---------------- Phone <br /> AddressZR¢ + .....------•--•--.............. ------------`- ------.C--•-•-•-------------• ------•-------•-•---••-•-•..... <br /> Contractor's Name ........ Phone............................. <br /> Installation will serve: Residence Apartment House ❑ Commercial E] Trailerr Court [3Motel E] Other [3Number of living units: ---/.. Number of bedrooms_ Number baths _� Lot size -------/__ ........_______........_------ <br /> Water Supply: Public system F]' Community system ❑ Private epth t ater Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand [j Gravel-❑ Sandy Loam Clay Loam El Clay ❑ Adobe C1 Hardpan ❑ <br /> Previous Application Made: (If yes date_-.-_--___,__._.-) No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No - ptic tank or cesspool permitted if public sewer is mailable within 200 feet.) <br /> r <br /> 'Septic nk: Distance from nearest well..--54'9__..-----.Distance from foundatiorg-----___ ____.....Material---- <br /> d/_____� o.. <br /> No. of compartments__---__ :------.__Size__ .�.__.e �i►.., 'Liquid depth------ ___-----------Capacity---------------- <br /> ._____ <br /> Disposa field: Distance from nearest well. Distance from foundation..`_.1P......� ____ <br /> Distance to nearest lot line_ ____....... <br /> Number of lines__.___._a_3--------------------Length of each line_ �%^ Q-�� -_.Width of <br /> trench..__.'._- <br /> ---­----- <br /> 1, <br /> Type of filter material____-_ _------Depth of filter material al_.__._ Q'�--------Total length_.__ ........................ <br /> Seepage Pit: Distance to nearest well------___-------------Distance from foundation-....._........ .....Distance to nearest lot line----------------- <br /> 171 Number of pits.._...-______________Lining material-----------------......Size: Diameter_--------------...___Depth-------------------------------_. f <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------_-----.__-.Lining material--_-..._--_.-_--_-_.____---_____•-_--. <br /> ❑ Size: Diameter--- ------------------------------Depth.-.---------------------------------- -------------Liquid Capacity_--------_--------------gals. <br /> Privy: Distance from nearest well_----_----------------------------------------Distance from nearest building------_.__:-------_............ <br /> _______._. <br /> ❑ Distance to nearest lot line----- -----------•---- ----------•-----------------•---------•-- -------•-•---------•---- -------------------- <br /> Remodeling and/or repairing (describe):----------------------------------- ------------------------------------------------ ----------------------- -------------- <br /> ------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 I s, and rules and regulati s of the San Joaquin Local Health District. <br /> (Signed)-•---- •----• •---- -------------- ------4sysf�einmrelatlil <br /> -- -- ------- ---------M--------- ------------------------------------- r and/or Contractor) <br /> BY:--- •--------•- . --••-- ------ - ------------ <br /> - - ----------- --(Title)---------------------------------------- ---- -- ---- -- ----- <br /> (Plot plan, showing size of lot, location of to wells, buildings, etc., can be placed on reverse side). <br /> - ---- ----------- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION,ACCEPTED BY-- --------------------- --------- DATE--- � <br /> REVIEWED BY --------- :. DATE <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------•------------------------------------.:_ DATE-----------•------------------------------------------------- <br /> Alterations and/or recommendations------------------- ------------------------------------------------------------------------------------------------------------------------------------•--- <br /> ---•------ -----------------------------------------•------------------------.------------------- ..........--..........-----------...................----------- -------•------------------------ <br /> ------•------------------- ------------------------.-----------------------------------------._..•------------------------..........----------- ------------------------------------- <br /> --------------------------------MM........... -----------------------------------------------------.-..------------------------------------------------------------------------- ------.. <br /> ----------------------_-------------- ----------- ----------- ---------------------------- ----------- ------- --------------------- -------------------- --------------- <br /> t <br /> FINAL INSPECTION BY:. -- Date---- .0 ' -------------------------------------- <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 k, Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 3M 3-•63 F.P.CD. <br />