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FOR OFFICE'USE- <br /> -------------------=------------------------------------- <br /> APPLICATION FOPv SANITATION PERMIT Permit No. <br /> ---------------------------------------- -------- <br /> ---------------- (Complete in Duplicafe) <br /> Date Issued --k7 <br /> ----------- 'This Permit Expires I Year From-Date Issued <br /> ' <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 No. 549. ' 11 <br /> JOB ADDRESS AN?-�LOCATION..&'-�-�� M. -Vz), W <br /> Owner's Name------- )------------------------------------7-7)------------ V-------------- Phone-(r-------------'A------------- <br /> Address------------- <br /> ----- -------- <br /> ---------- --------------------------------------------------------------------------------------------- <br /> Contractor's Name--------------- -- --- --------------­---------- 71---------- - - ------------------------------------ Phone....................-------------- <br /> Installation will serve: Resid nce Apartment House E] Commercial E] Trailer Court E] Motel Other <br /> Number of living units: J---- Number of bedrooms -1 Number of bafh5r-�­ Lot.size ----------- --------------- <br /> Water Supply: Public system El ' Community system Ll Private' <br /> Depth to Wafer Table 16- ft. <br /> Clay [:f.. Adobe❑ Hardpan E3 <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam El Clay Loam E3 .1 <br /> Previous Application Made: (If yes,date--------------------) No New Construction: Yes No ❑ FHA/VA: Yes E],;,r No <br /> TYPE'OF INSTALLATION AND SPECIFICATIONS: <br /> No septic tank or cesspool permitted if pu6lic sewer is available within 200 feet. <br /> 0 -M f <br /> Septi 4�/Tank: Distance from nearest well- ----Distance fro foundation---- -------- erta-------------------------------------------------- <br /> No. of compartments_____— Liq depth---tt-.Z-�, <br /> ................Si, <br /> _e...q. <br /> _ X__q <br /> uid :apacity------ <br /> D;sposal Field- D-,fance from foundation tv <br /> I&I(-Distance from nearest wel i - ---- -"_ ____._._Distance to nearest lot <br /> l <br /> r e -------------- <br /> Number of lines--------- Length f each line­--'� -Iqr-4�,-------------Width of trench-----4 <br /> --- ------ �flfer material--------------------- Total length--- <br /> Type of filter material- �epF " --"--------------- <br /> 1 'y, <br /> y� <br /> Seepage Pit: Distance to nearest well_________________---Distance from foundation--------------------Distance to nearest lot]-me- ------ -- <br /> El Number of pits______________________Lining material-----------------------Size: Diameter____._.___._._..___.___Depth___...__._.____I(--------------- <br /> ill . <br /> Cesspool: Distance from nearest well--------­------Distance from foundation--- ----------------Lining material-------_-"--_-_--_-_-- _ <br /> Size: <br /> aterial---- ---------------- -Size: Diameter------------------------ ---------Dept h-------------------A--------------------------------Liquid Capacity-------------------a1----- als, S)6. <br /> Privy: Distance nce from nearest well_ -------- --- - - ---- ---- fancfro "—e$;,b�51 building:_- - ----------- ----------- <br /> E1Distance to nearest lot line-------------------------------------------- -------------------------------------------------------------------------------------- ---------- <br /> Remodeling and/or repairing. (describe) ----------------------------------------------------•..----------. --------------------------- ------- ------------- -----------------1 ---------- <br /> -----------­--­-------- ------------------------- ----------------------------------------------------------------------------------------------------------------------------------1---------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------11---------------- <br /> ------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby.certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> n County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signedy- <br /> -- ------------------- -(Owner and/or Contractor) <br /> ---------- <br /> ---------- --------------------------------------------------------------------- ------------------ <br /> By:------ ------------------------------------------------I---------------7------- <br /> ------------------------------(Title)---------- ------------------------------------- ------------------- <br /> i. <br /> (Plot plan., showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 101 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----------=------------- ...... -------------------------------------------------------- DATE----------------- ----- -------------- <br /> REVIEWED BY_-----------_------------------------------ ------------------------- ­ DATE----- -- ...... ...... ------------ <br /> ------- ----- --------- <br /> BUILDINGPERMIT ISSUED-------------7---------------------------------------------------------------------------------------- DATE---------------------------------------------`--­­------- <br /> Alterations and/or recommendations:------ ------------ ---------- ----- -- ---- ----------------------------------------------------------------------------- ----------------- ----- ---- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------11--------------- <br /> ---------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- <br /> -------------------------------------------------------------------------------- -----­------------------------------------------------- ------------------------------------------------ <br /> ---------------------------------- . ..... -------- - ------------------------------------------------------------------------------------ -------------------- ------------- ------- <br /> - ( ------------------ <br /> N -- ------- <br /> ----------------------------- <br /> - <br /> Date - -AL INSPECTION BY:............. .. ---- `- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Stree I t <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> r66 0 REVISED 8-59 3M 3-'63 F.F.CO. <br /> Nr <br />