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I <br /> �1 <br /> FOR=OS FFI -- USE--� ` <br /> ---- _-"----------------- - - ---!M-"- APPLICATION FOR SANITATION PERMIT Permit No. .__,I h_ <br /> _Y <br /> ----------- ----------------- (Complete in Duplicate) / (S-- <br /> --- -- This Permit Expires 1 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 Ordina ce No. 549. <br /> JOB ADDRESS AND L CATI N......... <br /> 171 <br /> --- M ---- <br /> Owner's Name ----- -- -•-------- ----------- -------- --------- ------ - --------------------------------------------- Phone--.------ -------------• ----••---- <br /> A <br /> Address--- --- <br /> - <br /> .� --•--- ------ <br /> ----- <br /> Contractor's Name—-,._,:. - ------ 4 '� �"G-��.�------------------------ Phone-!!� <br /> �, --- -------------------- ------------------ <br /> Installation will serve: Resid. �nce Rj „partmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _-/-- Number of bedrooms--,4 Number of baths _fE_- Lot size _-_ _ _ __ ._ _ ---------____________ <br /> # .. <br /> Water Supply: Public system 2111�&mmunity system ❑ P,riyate ❑-ti Depth to Water Table Yt. <br /> Character of soil to a depth, f 3 feet: Sand ❑ Gravel ❑—Sanc)y,Loom ❑*;._Clay�Loam F] Clay E] Adobe Hardpan 0 l <br /> i <br /> Previous Application Made. ,�(If yes,date--------------------) No [ ~New Construction Yes❑ No FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank o cesspool permitted if public sewer is available within 200 feet.) <br /> ep c Tank: Distance.1from nearest well_________________Distance from foundation----_-_---___-_-1-.Material------__._____-___"___-_________----------___-__. <br /> ' No. of com artments Size --------------- Liquid de th-� -Ca Capacity P --------- q p. --- P Y <br /> Dispoosaall Wield- Distance��from nearest well Distance from foundation___ld_/__.'.Distance to nearest lot li`e_____ �_... <br /> I� , --------- <br /> -X---------------------- <br /> Type <br /> __.-__ --__-_-- <br /> Type of filter material__;F_-*' 4:G.-4o.'_Depth of filter material---_ /s--_-__-_-Total length--------------------- --------- <br /> Seepage it: Distance I'to nearest well_?' -----_Distance om f undation-"/._.�__A------ Distance to nearest lot line-­-S_J_____ y <br /> Number of pits---._-/-------------Lining mat erial__ -_Size: Diameter. __ Depth......._a __-____-___.__ �✓ <br /> Cesspool: Distancefrom nearest well---------- Distance from foundation.-----__s-_:-- `Lining material---------------------------------------- <br /> 1771 <br /> ______________°_--_-________-__-___.❑ Size! Diameter--------------------• - ----------.Depth----------------------------- ----------------j- --Liquid Capacity------------------ ---------gals. V <br /> Privy: Distance from nearest well-- _-__--------------------------------------Distance from nearest building------------------------------.--_-_____. <br /> ❑ Distance'to nearest lot'lineµ________________r____. <br /> Remodelingand/or repairing' (describe)-----------------------------------------------------------------------------------------------------------------------• ----•-------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- ------------------------------------ --------- - <br /> ------------------------------------------------p-------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------- - --------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ ---- <br /> I hereby certify that I }neve prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State aws, and iaules a d�regulltins of the San Joaquin Local Health District. <br /> '(Signed) - ----- --- ------- - -------- ------- ---(Owner and/or Contractor) <br /> -- ----- j <br /> BY- II ~` - (Title) �/ --------------- I <br /> (Plot plan, showing size of lot; location of system in relationtwells, buildings, etc., can be placed reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ <br /> - 1__-- _ DATE------ --- - -3 <br /> ------ ---------------------- ---------------- ---------------­ <br /> REVIEWED BY------ ------ ---------(M------------ - ------- --------- DATE------ <br /> BUILDING PERMIT ISSUED-1-'----------------------------------- - --------------- DATE----------------------------------------------------- <br /> Alterationsand/or recornmen ations-------- ------ ---- ----------------------------------------------------------------------------------------------------- ------------------------------------- <br /> ----------------------------- ------------------ Il I- <br /> ----- ---------------------------- -------------------------------------------------- - ----- ---------•-------------------------- -------------------------------- <br /> ------------------------------------------•-------------------------- ------------------- •--------•---------------- ----- •----- --------- <br /> I1[­­­---.­ - -------------------------------------- --------------- -------------- ---------------• •- ---------- <br /> --------------------------------------- ------ --------------- --------------- ---------- ------ ------------ ------- ------ I——--------- ------------------- ------- -------------------- <br /> FINAL INSPECTION BY:. 1 / •�. Date `�� �'7 ` <br /> 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street f24 Sycamore Street 205 West 91h Street <br /> Stockton,California r Lodi,California Manteca,California Tracy,California <br /> i <br />