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FO OFFICE USE' <br /> /y� ,:Z2 <br /> APPLICATION FOR SANITATION PERMIT Permit No.------------ <br /> --- -�-------- -- ------ ------ ------------------- (Complete to Duplicate) Date Issued <br /> . ___----------------_----------_____________________`__. This Permit Expires 1 Year From Date Issued 4 <br /> Application is hereby made to the'Sa`nJoaquin Local Health District for a permit to construct and install the A herein described. <br /> This application is made in compliance with County Ordina e Nor549. <br /> JOB ADDRESS AND OCATION- ---------- --- - • 01 6 <br /> ± <br /> n�, l <br /> Owner's Name lie- '���iV F -'----- Phons ---- ----•-- <br /> ----;-- <br /> -�o-----� -r - <br /> Address = ------------ r <br /> �-. , <br /> `n ------ Phone---:....1 }- - <br /> Name----------------�.k/�3�-��.��-.__.------�=K�---------------•----------�-------------=---•-•--••-•------------•- Ir- <br /> -Contractor's . a��.-��.&, <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel E] Other E]Number of living units: ___�__INumber of bedrooms __ . Number of!baths ----V- Lot size ---- Q___. .__.1-p_7---------__________________ <br /> Water Supply: Public system R Community system ❑ Private E] Depth to Water Table .._____- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam-ElClayLoam ElClay ❑ Adobe[Hardpan ❑ <br /> Previous Application Made: (if yes,date-----:J-------------) No [ New Constructions- Yes ❑ No FHA/VA: Yes ❑ No [� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:( q <br /> ,(No septic tank or cesspool permitted if0­4&,--.� <br /> lie sewer is available within 200 feet.}f <br /> x Septic ank: Distance from nearest well__ Distan e•fJom fgund9tion-----l:Q_---ma tial=_ _-_ — <br /> No. of compartments_.._-0" -.-A__�_____Size._ X ? .___Liquid°deipth-_..__ � Capacity__.__ _ <br /> - <br /> Dispo I Field: Distance from nearest IL____.-- Distance from fou;It/. ._ __ r � <br /> _ ____.�Dli�sta,�e�tb-nearest lot line_.... <br /> :-Number:of lines___________fit- _-_# __Length of each linT __- _0 _ Wid#h oftrench--- ----------------------------- <br /> A ; <br /> f <br /> I' Type of alter material_!__ _-_/_�t i G_Depth of filter 'material__j4V!—___y__-Total length_____ ______________A ------- <br /> Seepage Pit: Distance to nearest well /.-C _ Distance from foundation____.:�� Distance to nearestI t line I q <br /> Lid" Number of pits-___;___________Lining material__ ;-.Size: <br /> Cesspool: Distance from nearest well__________k_____-Distance from foundation- Lining material________________________________ <br /> Size: Diameter------------------- th-------------------------- ---.--------Liquid Capacity---------------------------- als:Y <br /> -- <br /> Privy:i Distance from nearest well____________________________g______.____-___._Distance from nearest building-____-__________________._.___________-._. <br /> ❑ Distance to nearest lot line_---------- •--------------}---------------------------------- <br /> Remodeling and/or repairing (describe): --------------------------- -----=-----------------------•-----•-•-------------------- -------------------------------------------------------- <br /> t i i <br /> 1 <br /> ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ �— <br /> �; } t <br /> I hereby certify t Wrnde <br /> epared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,/S to law nd regulations of the San Joaquin Local Health District. <br /> Le <br /> (Sig n <br /> --------- - ------------------------------------------------------------ -------------------------- (Owner and/or Contractor] <br /> .i S <br /> By: ------------------=-------------------------------------------------------------�_- ..............:_ (rtlel _ ` -- <br /> (Plot-pla , showing size of,lot, location of system in relation to wells, buildings, etc., can be placed onRreverse side). <br /> J FOR DEPARTMENT USE ONLY , <br /> APPLICATION ACCEPTED BY ----- ----- ------ - ------- - ------------------ - DATE. -... <br /> fi------------------ -------- <br /> REVIEWED BY--------------------------------- ----=-- ---------- ---- ------------------------------------------ DATE-------' -------- ----------------•------------ <br /> BUILDING'PERMIT ISSUED---------------------- – {--------- DATE---------------------------------------------------.......... <br /> Alterations and/or recommendations:-----/___. 4 – il ' <br /> . ..... --- --- -----------------------------••-----------------•------------------------------ <br /> ------------ <br /> ------------------------- <br /> -- __ <br /> ---- -------------------------- <br /> t <br /> ,o ' F <br /> t t <br /> -----------------------------__-------------------------------_---------------------------_---------------_----_________________-------- <br /> _____-------- <br /> _---------------------____--------------_---------_----------------------- <br /> ----------------______-------------_----------------------_---------------___---__--------_-------------------------------------------------------------------- <br /> ----------------------_____------____________________ _________ <br /> FINAL INSPECTION BY: s Date------" :.. -_~�o.1------------------------------------•-------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E13-9 REVISED e•e9 r.P-Go,8M 6-so <br /> I <br />