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FOR OFFICE VSE. / <br /> .. = -61 <br /> ___________________ __________________________________ APPUCATI~ON FOR SANITATION PERMIT Permit No. ____1 <br /> ---------- -------- ------ ---------------- ------- - (Complete in Duplicate) <br /> �._ Date Issued ---••-•--. - -Cod <br /> ----------------- --------------------------------------- This Permit Ex ices't'Year.From ,Date Issued�LL <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 applicafion is made in compliance with County'Orcl aiw nce No. 549. <br /> i f <br /> JOB ADDRESS AND LO ION--------------1 ' 1 �'_ _. ------ -- <br /> _ _ _ <br /> Owner's Name----- �' G?rR,d ---• --= ? 'Phone-•-.X ��- .�3d ,J <br /> i t ; <br /> Address-------------- 1 S� <br /> Contractors Name----- � ��- / ' <br /> Phone- <br /> Installation will serve: -Residence Od Apartment House ❑commercial ' ] Trailer Court❑ Motel,E] Other ❑ - <br /> ;Number of living units: _1___ Number of bedrooms g--- Number of baths _a. Lot.size ------------------------ <br /> Water Supply: Public system ❑ Communitsystem ❑ Private. Depthto Water Table <br /> `Lo <br /> 4' t <br /> Character of soil to a depth of 3 feet: iSand ❑ IGravel ❑a'Sa'ndy Loam E] -Clay Loam ❑ Clay ❑ AdobeEC Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------- No 2. New Construction: Yes ® No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 0 fr <br /> (No septic tank.or cesspool permitted if.public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well.-,.5-0-------Distance from foundation_____!&'________.Material i_4___ <br /> No. of compartments-.------ Liquid de Ih_-�-----. # I <br /> --- ---/,Size ---�- �- q . � �----------.. peaty---��li�--C�-..� : <br /> Disposal Field:. Distance from nearest well_._� ----------Disfance from foundation----/!___-......Distance to.nearest lot line-------5....... <br /> Number of lines_____________! __- _____- Length of each line__________ _ _ . <br /> . � g -E�l�------- Width of trench---'--�--------------------•.. <br /> Type of filter material________ _Depth of filter material--------- ---- - Total length_________��_O__�______________ <br /> Seepage Pit: : Distance to nearest well______________________Distance from foundation...................Disfance­fo•,near'es}-lot line................. <br /> ❑ Number of pits_______ •-------------Lining material----------------------Size: Diameter%------------{' } ,Depth------------------.-----_- <br /> Cesspool: Distance from nearest well-----------------Distance from'foundation---------------___,:_Lining rnaterval----:____- -_____--------- <br /> ._ <br /> Size:❑ Diameter_--------- _ --------------------------De th_.,__ r ------- Liquid Capacity.'_,__-,: - --=---}-------- gals. <br /> Privy- <br /> v <br /> Privy: R Distance from nearest well__.____,..____--- -y"--__________________Distance from nearest°building------------------____� ?___.___..__._. <br /> Distance to nearest lot line ==-' ----------------------------------------•----•-•---•- ---- =----- ------ ---- <br /> Remodeling and/or repairing (describe):__-.it-------------------------- l L T ' <br /> R x� <br /> I <br /> t I r <br /> ------------------------------------------------------a-----------=-- -------------------------------------•••----------•----------------------------- ----•- ------------------ -------•----------------------------------- <br /> I hereby certify that Fhave'prepared this application' and that the work will be done'in accordance with San Joaquin County <br /> ordinances, Stat�Iaw�s` rules-a -d regulations of the Sa Joaquin Local Health District. r �si ned �-- <br /> ( 9 ) ------------------------------------------------- <br /> i <br /> = = :w (Owner and/or Contractor) <br /> r , <br /> By:----- =•--------------------------- .............. '`------------`---------------------------------------------...(Title)-----------'------------------------------------- ------------ <br /> (Plot plan, showing size of lot, location of sysem in relation to wells,:buildings, etc., can be placed on reverse side). <br /> ` ) rFOR DEP RT ENT USE ONLY f1 <br /> APPLICATION ACCEPTED BY------ <br /> _. - z <br /> __. _— ......'T..w_,.:..�...__ .= _�-.__DATE-=--�..` ---��-- -� ---------•---- --------- <br /> REVIEWEDBY------------- ...------=- ------•<----------------------- :. = DATE---------------------------------------------------- <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------------•---`--------°----- T --------------------------- --------------------------------- <br /> Alterations and/or recommendations:___________________r____ '� m.. 4 <br /> -•------------------ ----------------------------- ------ ----- ------------------------------------------------------------------------------------------------------- <br /> -------- t •-------------•----------•-••------------------------ <br /> ------------- ----------------------- ---------- -------- ----------- ------- ---------- ----------------------------------------------------------------------- -----------------=-----------=------------ <br /> FINAL INSPECTION"BY:_�_; r�-l- -- --s----- -'--� Date------- /�' - ? /------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205.Weaf 9th Street <br /> Stocktonr California Lodi,California Manteca,California Tracy,California <br /> EH-9 REVISED 6-59 r.P.CD.2M 6.60 <br /> r - r <br /> F <br />