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OF FICE USE: jW <br /> ;Z11 <br />----------- ----- ----- ...... -------------------------- APPLICATION FOR SANITATION PERMIT Permit No. <br />-------------------I------------------------------------- (Complete in Duplicate) 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 No. 549. <br /> JOB ADDRESS AND LOCATION. .........15MA? <br /> LOCATION._.....1. / 77 ------- ..V-51d .............. ..................................................... <br /> Owner's Name----------------),Q7rl. ----------•-------•-----------.._._..._---- --------------------------------------------- Phone.----•--......_. <br /> Address._ J.---------------- "We ------ <br /> ----------------------------------------------------- ------- <br /> Contractor's Name--------------- --------- -e—ga-iA ........ ................... Phone....-----....__.................__. <br /> Installation will serve: Residence UEtApartment House E] Commercial E] Trailer Court 0 Motel El Other E] <br /> Number of living units: __I___ Number of bedrooms ._R_ Number of baths __-I___ Lot size ............. <br /> Wafer Supply:, Public system [Community system C] Private-0 - Depth To Water Table -------- ft. <br /> Character of.soil-to a depth of 3 feet: Sandi-[] Gravel [] 'Sandy Loam ❑ Clay Loam Clay E] Adobe[Hardpan C1 <br /> X_ ctio <br /> Previous-Application Made:� -.[If yes,date.__.____.- No Nemi,'Constru n. Yes [ErNo 0 FHA/VA: Yes 0 No [_1 <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 well Disfan'cr.o f f d ti6n.�Zl!...........MateriaL.,....... <br /> _Q un a .............................. <br /> No. of compartments____i__ -iquidr depfK <br /> Size-.-3�22 . -XILL A ...........Capacity. <br /> Disposal Field: Distance from nearest w 11 —-------Distancefromfoundation./P................Distance to nearest lot line___.'S:......... <br /> Number of lines Length of each Ii Width of trerich <br /> 0 filter rinqL <br /> Mal K_ f filt I tai length <br /> Type of filter �erial._�­ - -----------------___-- <br /> Seepage <br /> Diftance to nearest &eline---- ------------ <br /> Seepage Pit: Distance to nearest:well---------—__-----Distance from 4ou tion-.9 <br /> 161arn <br /> Number of pits--L------�/------------Lining material-, 11r., -------Depth------!,�_5--------- <br /> Cesspool: Distance from nearest well-----------------Distance'from foundation--------------------Lining"Imateri ad------------------------------------ <br /> ❑ Size: Diameter----•1_' ------Depth------------ ----------------------------------Liquid-,Capacity.............................ga <br /> Privy: Distance from near6st well__________ -------I----------------Distance from nearest bu.ilding-_:--------------------------------------- <br /> ❑ Distance to nearest.lot line---------------- -- f <br /> ------ <br /> -----------------------------I---------......I ----------- -------------------------------------------------- <br /> Remocleling and/or repairing <br /> .................... - -- ---------- <br /> ---------------- <br /> ----------­---- .1-------- - ----------- <br /> I hereby certify.fli,at I hay prepared f application and that +he work will be done inlaccorda_n_c�e�wlf �anoa�quin County <br /> ordinances, State laws,'.and rules and regulations of the San Joaquin Local Health District. <br /> ---- <br /> (Si ned' �, ------ --------1­1%------ <br /> --------- ---(Owner and/or Contractor) <br /> By:_---------;_1......................... <br /> sT <br /> 4--- --------- ------------------------------------------------- ----------------------- -----------------­- <br /> (Plot plan, showing size of lot, location of system id/relation to wells, buildings, etc., can bep laced an reverse side). <br /> _FOR'DEPAR-TMENT USE ONLY �e_ % <br /> APPLICATION ACCEPTED BY__'_"_-—----------------------- DATE-------------- <br /> ------------------- ...... <br /> ----------------------------------------------------------------------------- <br /> ----------- <br /> REVIEWED 6Y--------- /-=---------- DATE----------------------------------------------------------- <br /> BUILDING PERMIT ISSUED-------------------------- ------------ ----------- - ------- DA,;E---------------------------------------------------- ------- 4 <br /> Allferajjan"nd/or 4,'f')n �1;1/ ------x ........ <br /> /0 recommert ----- --- ------------------------------------------------------------ <br /> ---------- ---------------------7----------------------------------- <br /> - ----------------- <br /> ---------- ------- ----------------------------------------------------------------- ------ <br /> 9y------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------­---------------------------------------- --------------------------------------- ------ --------------------------------- ----•---•--.....------------------ <br /> ----------------------------------------- - ----- -------- ------------- ------------------------------------------------------------------------------------------------------------- ----------------------I---------------- <br /> FINAL INSPECTION BY:. ... .. .......r----------------------------- Date----------- ---- --------­­------...... <br /> rSAN JOAQUIN LOCAL HEACTH DISTRICT <br /> 130 South American Street 00 West Oak Street 124 iycomar*Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 0.59 2M 53-62 ATLAS <br /> 42� <br /> k� . -} <br />