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1 410– <br /> P" APPLICATION FOR SANITATION PERMIT <br /> l'r NA !. Permit No. ---- <br /> � <br /> { (Complete in Duplicate) Date Issued __f_ __ <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. S49. } <br /> JOB ADDRESS AND LOC TION_%_?�,� ____� <br /> ---------------------------------------------------------------------------------------------r---------- <br /> Owner's Name-- -------------------- - -------------------=---------------- Phone--------------------•--------------- <br /> Address-- ------------K_4_o?.V--' &-f4*P_� <br /> Contractor's Name------------ ------------------------------------------ '--------------------------------------------- Phone----------- ------ <br /> Installation will serve: Residence PR�-Apartment House [❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __I_-_ Number of bedrooms __crt_ Number of baths _/_= Lot sizef-e.1-.(f`___ ____________________-_ <br /> { <br /> Water Supply: Public system El Community system ❑ Private De11p. <br /> t pth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g-OHardpan ❑ <br /> Previous Application Made: Yes ❑ No P�r New Construction: Yes ❑ No PR"�FHA/VA: Yes ❑ No [T-" <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or`cesspool permitted if public sewer is available within 200 fee+.) ` <br /> I <br /> Septic Tank: Distance from nearest well__�z�_X__Distancel!from��foundation---- p--------Mata__, _ _C�'__________________________ O <br /> No. of compartments______--------_--- Size_ �?___ �frp.---,___Liquid depth_--__ ..________-Capacity___—EM---_-___ y ` <br /> Disposal Field: Distance from nearest well-_9117 -----Distance from foundation__`�----------- <br /> �____-__Distance to nearest lot li��_�_�_-.- <br /> Number of lines--- Length of each line--- a0-------------------.Width of french----9.Y--_-__---------------- <br /> Type of filter material--/ Depth of filter material----/ee� ------Total length--------?&_`---------------------- <br /> Seepage <br /> ______________ ____Seepage Pit: Distance to nearest well.___/A!P_ _Distance from fo'��' ndation__-je______ Distance�e to nearest lot line_ <br /> [1� Number of pits-----4-------------Lining material__XQ_,+XI--Size: Diameter---,..�x.7-__ --__.Depth-----`a ----------:____-- � <br /> I. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation__________________.Lining material_____._______________________________. <br /> ❑ Size: Diameter----!------------------- -----------Depth_._------:----------='------------------------------Liquid Capacity----------------------------gals. i <br /> . 'r � <br /> Privy: Distance from nearest well._ -__---____ __________________----------_Distance from nearest building_____-.----------------------------------- <br /> ❑ Distance to nearest lot line------------------------------------•- ------------------------- ---------------------_---------------------------------------------- �. <br /> Remodeiin and/or re airin descnbe ----------------- .,�. ------------------------------------------------ <br /> 5 <br /> -----------------------------------------------------------­1---------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 hilaTions of the San Joaquin Local-Health District. <br /> r <br /> - - - - -- ------------- <br /> --------------------- <br /> �-.. - ; --- - -- __ Contractor] <br /> (Signed)----- ----------- <br /> ------------------------------ <br /> By <br /> Sy-----------------'•-------------- -• ------ -------- - - ------------------- ------------- -.- (Ti+le] 6��'x1- /t <br /> (Plot plan, showing size of to ocation of system in.relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> 4� <br /> APPLICATION ACCEPTED BY �'---------------------- DATE <br /> ----- --- ------ -------------------------- <br /> REVIEWEDBY------------------------------------------- - ------------------- - --- -------- ----------------- '------------------------ DATE----------------------- . <br /> BUILDING PERMIT ISSUED--------------------------------- --- ------ --- - --- - - DATE <br /> Alterations and/or recommendations:--------------------- ---- - -- -----------------------.r --------------------------------------- <br /> ------------- <br /> ------- <br /> I. <br /> --------------------- - <br /> ----------------------------------- ------ ----------------------------------------------------------- ------------- ----------•---------------- <br /> •-------------•-------------------------- -- -------------------------------- -------------------------------------------------------------------- <br /> _.�.. -------------------------------I=- <br /> _tk - I " <br /> -------------------------------- --------- -------------------------------------------------------------------------------- --------------------------------- <br /> FINAL INSPECTION BY:. ----- ------v�(� <br /> II k <br /> Date.---- r =T1-------- ---------------------------------•---- <br /> > `-------- - ------ -----� � �--- ---- - <br /> � t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton,California Lodi, California Manteca, California Tracy, California <br /> ES---9-2M Reviseci 1.57 F.P.CO. <br /> l4 � <br />