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FOR OFFICE USE: <br /> -a - ---------------------- _ <br /> ------- -- -- -- _ ___ _ __ -------- APPLICATION FOR SANITATION PERMIT Permit No. ___ .-------------- 6 <br /> ------- -- ------------------------------- --------- (Complete-in Duplicate) <br /> Date Issued <br /> ............. ----- ----------------------------.... 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 N�- 4415P <br /> 9. <br /> JOB ADDRESS AND <br /> ELOCATION-----��2;2------e ,- J �' ------------------ <br /> -° <br /> ------------•----------------------------------•------------- <br /> •-------------- <br /> Owner's Name---------(, - --•--_A-?11r.V-----•--------------------- ----- --- ---- - Phone-----•-------------- <br /> -- ----------------- - - - ------------------------------------ <br /> Address--------- -- i�F' -----=------- <br /> Contractor's Name--- �'��Q^#-ll -{ .� /" --------- --•--- Phone------ -----••-•--•---------------- <br /> Installation will serve: Residence RL'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units. _/-__ Number of bedrooms _� Number of baths.--4- Lot size er�_o----_ /%�., ------------------------ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water TablegQ ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe gr-Vardpan ❑ <br /> Previous Application Made: (if yes,date---.. ............. ) No [GY New Construction: Yes ❑ No ®--FHA/VA: Yes ❑ 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;, Distance from nearest weft----------------Distance from foundation--------------------Material ------------------------------------------------ <br /> Ir�rir+ti-'r r�qqNo. of compartments--------------------------Size-------------------- -----------Liquid depth.-- ----- ---- - ------- Capacity----------------------- <br /> Disposal,-Field: ► Distance <br /> from nearest well-----------------Distance from foundation-------------------.Distance to nearest lot line----_--_-.--_____ <br /> Number of lines.----------------------------------Length of each line-- -----------.--------------.Width of french-,--------------------------------- <br /> Type of filter material.........................Depth of filter material----------------------- length------------------------------------------ <br /> Seepage Pit: Distance to nearest well---------'"'----------Distance from fo pndationDista`� to nearest lot line <br /> --A?- <br /> [ Number of pits--. __/___._.._.--Lining material <br /> �� ------- Size: Diameter--�� -- <br /> -- ----- .2.4—Depth- ----- --------- <br /> Cesspool: Distance from nearest well ................Distance from foundation --_----.------- -.Lining material-------------------.----------------- <br /> ❑ Size: Diameter- -- ----------- -- ---- --- ---- -Dept h----------------.-----------------------------------Liquid Capacity-- ----------- -------------gals. <br /> Privy: Distance from nearest well---. _................................Distance from nearest building-----------------.------------.----------- <br /> ❑ Distance to nearest lot line -------------- ------ ---------- - ---- --------------------------- <br /> Remodeling and/or repairing (describe)---------------Ig ------.----------.--.--_---------------------------- <br /> -------------------------------------------------------------------•-----.------------------------------------------------------------------------------------•-------------------------------------------------------------- <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) � !'t --------•---------------------- ------- - - --(�[ Contractor) <br /> 4�By:----------------------------------------------•-- ------ = - {Title) <br /> (Plot plan, showing size of lot, location of sys in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----.---'----' DATE..�_" �--"-'-- ----------------------- ---- <br /> ------- -------------------- ----- <br /> REVIEWEDBY-------------------------- ------------ ---- --------------------------------------- - ---- DATE-------------------------------- <br /> BUILDING PERMIT ISSUED-------- -- ------------------------------------------------------------------------------ ----------- DATE------ ---------- <br /> Alterations and/or recom endatio s:----- ------ ------ -- -------------------- -------- ----- . <br /> ------------ ° - --- ¢ = - - - ------------- <br /> ---------- -�l-c _ <br /> -- --- - --- - - --- ----------- <br /> - ------ W° -----------vim, -- ..... -------------- ------- ----- <br /> FINAL INSPECTION BY:- -.-�+V. A ----------------------- Date Date.- -r._z, <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 /> E.H.9 2M 1.67 Vanguard Press <br />