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/. FOROFFICE USE: <br /> ----- 4 <br /> ---------------------- <br /> ---------------------__------------ APPLICATION FOR SANITATION PERMIT Permit No. _._1_. .l.G6 <br /> F <br /> - ----------------------- ----------:---- ----------- .t. (Complete in Duplicate) VP�A-3-------- ---------- This Permit Ex ires i Year From Date Issued 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 No. 549, <br /> JOB ADDRESS AND LOCATION__ -. _�e_.4_ .__---_ - _-in-M- - , <br /> Owner's Name------- --t------ L1-.k1 - 5 ------------------- --------------------------------------------- -------- Phone-_..--------------...:_ <br /> Address-.-------3-k-1c --------5-V--h- - -------- -- <br /> -A-r----- -------------------••------- <br /> R <br /> Contractor's Name---- Q_Lt2_. __ -' ____________•_,,,- <br /> -•------- <br /> --------------- Phone----------------------------------- <br /> Installation will serve: Residence N. Apartment House ❑ Commercial :E] Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __----- Number of bedrooms'_Z Number of baths ---I--- Lot size _-- -----NC _ _ <br /> Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table tab ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam E] Clay [-IAdobe ® Hardpan E] ', <br /> Previous Application .Made: (If yes,date-..--..---_---.-_-.] No CK New Construction: Yes ®. No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATfON'AND SPECIFICATIONS: i ti <br /> (No septic tank:or cesspool.permitted if public sewer is available within 200 feet.) <br /> i t € € <br /> Septic Tank: Distance from nearest well--- _p_----:Distance from foundation----- <br /> 1_ _--._---Mater�al--x- -+-i1_QC3_�__.-_-______ \t� <br /> [ No. of compartments--------Z-----------Size_�'_X.Q,.)C,_S---_----Liquid depth--------4--------------Capacity- <br /> Disposal Field: Distance from nearest well_- 'Dr___Distance from foundation____1-Q�-._-_---.Distance to rie rest lot line------ <br /> N of lines_i-_-__ - a----......... <br /> -.._.Width of trench..----_Z- • -r--------- ----- ( /) <br /> c -- - --�-----------=-"-"----Length of each line----------- v'v <br /> Type of filter mate rial_�,f,__0_S„KDepth of filter material------�_fS11-:----Total length-' ---_----- --4- -=__- <br /> i' ' ------ <br /> Seepage, Pit: Distance to nearest well-_--.1,.0_C-------Distance from foundation-__..1_0d._-_Distance to.nearest lot line_S'/ <br /> Number of its--I---L--------_ Linin material. {- 0-�. Size: Diameter-_ 1 <br /> P I g x Depth- S <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-----.---------------Lining material--.-.-_----.-------------_------- - <br /> ❑ Size: Diameter ---------------------------- ---bpth _f_ - - ---------------Liquid Capacity---------------------------ga._. 1Z <br /> Privy: Distance from nearest well--------__------------ - - -------..Distance from nearest building <br /> -- c�--t g ............ <br /> Distance to.nearest lot line -------------•---------------•-----------------------------------=------------------------- <br /> Remodeling and/or repairing {{dscribe)----------------------------------------=--------------------------------------------- --------------- ' <br /> ----------------------------------------------------- <br /> ------------------------------ +-•------- <br /> ------------------•-----------•------- --------- <br /> ------------------------------------------ - <br /> . � t <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)___ A ` -- _ (owner and/or Contractor) <br /> BY: ----------------------------------------------------------•-------------- ----------------------------(Title),,-------------------------•--­ "- - -------------_------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can belaced on reverse side).. <br /> ( r FOR DEPARTMENT'USE ONLY F <br /> APPLICA7fON ACCEPTED BY-.-- ........ ---------------------------------- --- DATE--- l i f F <br /> REVIEWED BY --: '�"`� ` DATE <br /> BUILDINGPERMIT ISSUED-------------------------------------------------- =-- — --------------------- ------------ DATE------------------------------- ------ <br /> ----- <br /> Alterations and/or recommendations:---`------ -- - <br /> --------------------------•----------------------------•------------•------------ -----••-----•------------------------- <br /> -------------------•--•-----------------------------------------_"---------------------------"-------------------------------------------•-------- ----------- <br /> i <br /> --------------------------------------'n--....---...-----------------------.-------------------------------------------.-------------------------------.............................. <br /> -----_..__.----...------_.----..--.....- i <br /> FINAL INSPECTION BY:- +" ----------7 Date-------- ±....... 7 7-P4 <br /> SAN JOAQUIf—LOCAL'HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi, Manteca,California <br /> y California M�-''+,. Tracy,California <br /> E5 9 REVISED S-59 3M 3-'63 F.P.CC. � <br />