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FOR OFFICE USE: <br /> -------------------:--------------------- ---------------- Permit No. <br /> APPLICATION FOR SANITATION PERMIT <br /> /7 <br /> Date <br /> (Complete in Duplicate) Issued -------------- <br /> V-5 <br /> -- -- <br /> ...... ----------------------- ----------- - This Permit Expires Year From Date Issued <br /> -------------- -------------- I <br /> i <br /> Application is hereby �nacle to the Son Joaquin Local Health District for a permit to construct and install the work b e�Arin d escribed? <br /> IL/I <br /> This application is made in compliance with County Ordinance No. S49Vj , <br /> JOB ADDRESS AND LOCATION.------- . . . ..........­--------------- <br /> Owner's Name-------- --------------_------------- -- - Phone-----------------------------••----Phone------------------------------------ <br /> Address.---- ----".J- I f----------------------------------------- - - - - -------­----------------------- <br /> OF----zdzrllx�------------- <br /> Phone� <br /> -- - <br /> I Y- V <br /> Contractor's Name_- ._ _ _a4l�--------x---------/Z9:46_4_&��--------_7---------------------------- <br /> Installation will serve: Residence Apartment House El Commercial f El Trailer Court [] Motel 0 Other El <br /> ;&,a--- -- ------------------- <br /> Number of living units: Number of bedrooms,_=> Number of baths ----------- <br /> ----- Lot size ------- <br /> Water Supply: Public system [I Community system [I Private N Depth to Water Table .... --- ft. <br /> Character of soil to a depth of 3 fe;+: Sand ❑ Gravel E] Sandy Loam El 'Clay Loam [] Clay E] Adobe 0 Hardpan 0 <br /> Previous Application Made:` {If yes,date_..__-- -.-) No po New Construction: Yes N No Ej, FHA/VA: Yes E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permiffe.d if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from inearest well Distance from foundafion___,_(6Z--------- --------- <br /> VOC-11-------------Liquid depjh , ---------- <br /> No. of compartments.-------Z; ---------- --Size--- ------------Capacity... <br /> Disposal.Field: Distance from nearest well-moo---t. Distance from foundation__/K----_......Distance to nearest lot kne__1�5../..... <br /> Nd.mber of lines------�q--------------------- ----Length of each line---, ------Width of trench.-- 2-c-11---------------------- <br /> _,'5._�e�-,_-_Depfh of filter .............Total length-----/,44-x---=------------------------ <br /> of filter material. <br /> tante to,nearesf well___._----------------Distance from fou'ndati'on-------------------Distance to nearest lot line----------------- <br /> Seepage Pit: <br /> � - - -___ inin <br /> e <br /> Num f - its--------`-.--. . ----------Lining material---------- ------------Size: biameter-----------------------Depth----------------I--------------- <br /> 0 P <br /> c, from <br /> rest well ......... --------------------Lining material........._.....:.____.--_-..._.___._ <br /> ❑ from rest well--------------- Distance from foundation. <br /> Cesspool: Distance <br /> S S ..... . .... <br /> ize: Diameter---------------- ----------------------Depth---------------------------------------------------Liquid Capacity------ ---------------------gals. <br /> D <br /> nearest well e <br /> fr <br /> Privy: Distance 4o"m neeine well._______ -------------------------------- _Distanc� from nearest building------------------------------- ---------- <br /> Distance to nearest lot line..----------------------------------------------------------------------I---------------------------------------------------------------------- <br /> ❑ <br /> r.repairing (descr;be):---------- --------------------------------------------I---------------------------I------------- <br /> Remodeling and/o --------------- <br /> ----------------------------------------- <br /> ---------------- -------------------------------------- <br /> - -------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------- <br /> - ---------------- -------•------------------------------- ------------ -------------------------------------------------------- <br /> ------------------------------------- ----------------------------------------------------------------------------- - ------------------- <br /> -- <br /> I hereby certify that I have prep'ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of fbe San Joaquin Local Health District. <br /> ---------- ......(Clw _aad/or Contractor) <br /> ------------------- ---- ------------------- --------5i ned --- ------- ----------------- - <br /> ---------- ---- ----------------------------- --------(rifle)--------------------------- ---- ---------------- --- ---------- <br /> By:-- ---- ---- -- ----- - ---- -- ---------- <br /> i, f lo; S..etc., can 6 reverse side). <br /> (Plot plan Ing size of lot, location of system iri:relation to wells, building e placed on <br /> FOR.DEPARTMENT USE ONLY <br /> APPLICATION :ACCEPTED BY---------------------------------------- --------------- ----------------- - _ DATE <br /> REVIEWEDBY- ---------------------- -------- ------- -------------- ------------------ DATE <br /> BUILDINGISSUED----------------- <br /> -------------------------------------------------------------------------------------------------------------------- <br /> - <br /> PERMITISSUED------------------------------- ------------:----------------------------- ----------- --------------- DATE--:----------------------------------------------------------- <br /> Alterations and/or recommendations--------------------------:--------------------- ------:----------:------------------- --------•-•-•-----------------•--------------------------- •­----------- <br /> -------------------------------------------------------------------------------------------------- <br /> ----------------- ---- <br /> -----------­----------11--------------------------- --------------------- <br /> ------------------------- --------------------- ------------------------- -------• --------------- <br /> --------------- -.....................------------------------------- -------------------------------------- <br /> - t ,: --------­---------------7----------------------------------------------------------------------------------------------- <br /> ----------------------------------------------I------------------------------ ---------------- <br /> i1 ----------- <br /> ----------------------------- -- --------------------- ------------------------------------------------------------------- -------------------------------------- ---------------------- ------------------- <br /> FINAL INSPECTION BY:...--� ------------ Date-----...... --------- ----- --- --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> Ca 9 REVISED 61-59 3M 3-'63 F.P.C[3- <br /> r. L <br />