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FOR OFFICE USE: <br /> ------------------------------------------ -------- <br /> ---------------------- ------ --------------------------- <br /> --------_______________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. ....... ... /U[/ <br /> --------------------------- ---------- ------ ---------- (Complete in Duplicate) ba+e�!Issued ---���{-•�7 <br /> ------------ -------------- ---------------------------- This permit Ex fres Year From Date Issued 1-114 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe <br /> This application is made in comRliance with County Ordinance No. 549. ;€ <br /> JOB ADD ESS AND LOCATION l _ r =" --, -------------------------- <br /> Owner's Name "f ----•• ---•-------------------- -------------- -- ----------- ----------------------------- Phone------------------------ <br /> T--I--- <br /> lJ �j <br /> Address-------------��_,_7 . ,7_ �l <br /> ---- --- -------------------------------�-------•--�----••------------- <br /> Contractor's Name----- -- _ l 1— ------ Phone----------,--`•--.-_------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trai€er Court ❑ Motel D.II Other ❑ <br /> a <br /> Number of living units: 1------ Number of bedrooms • _-._ Number of baths -!~.:_ Lot size <br /> --D <br /> _ ----------------- <br /> Water Supply: Public system .E] Community system El Private X Depth to Water Table �.Cft. ~�~ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam 2 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date... _..-„........) No New Construction: Yes :L& No ❑ FHA/VA: Yes ❑ No ❑ <br /> u <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---4-(I-------Distance from foundation-_-_ -----Material ------------------------ -------------------- <br /> �J No, of compartments__21-.________.--Size.__L_ _ _L+:?471-_Liquid depth---------t7/.-_ ----------Capacity_404 <br /> 4I <br /> Disposal Field: Distance from nearest,well-_d~4------.-Distance from foundation-----.1_b'....._.Distance to nearest lot line----,$!7------ <br /> Number of lines____ _ I__/-_ Length of each line_ (� Width of trench---.2-�_-�___________________ <br /> Type of filter materi ------------_--------AL--Depth of filter material ---.Total length---a° _jQ--------------------------- <br /> Seepage <br /> ------ <br /> p g FDistance from foundation-------------__---- Distance to nearest lot line----------------- <br /> � � t <br /> Seel a pit: Number of pifs.rest we---------------------- <br /> Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- l <br /> r -I' 'f it 1t <br /> Cesspool: Distance from nearest well_________________Distance from foundation ------ <br /> �A__.Lining material_lt_..-_-_----_---- .______---.--. <br /> ❑ Size: Diameter--.------------------------------ ----Depth------ --------------------------------------)--1--Liquid Capacity-------------- --------------gals. 3� <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----1i_._____________-__-_-_--.------_ <br /> ❑ Distance to nearest lot line--- ----------------------------------------------------= ----- -----------------1�------ ------------------------ <br /> Remodeling and/or repairing (describe: - ---------------------------------------------- ------ <br /> A....,..,.. ------------------------------III----------------------------- Z <br /> --------------------- -----------------------------------------------------------•--- -----------------------...------------------------------------------------------------------------- <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 regulations of the San Joaquin Local Health District. k <br /> ----------- Y[Si <br /> (Signed)- - i-' --------- ----- --Owner! <br /> and/or Contractor] (4 <br /> r - <br /> BY:-------------------•---•----------------- ---------------------------- ------------------------------ -- ---------- --------------(Title)---------- -------- ------�•--- ------ ------ <br /> .._.e0 . <br /> (Plot plan;showing size-of-lot,--location of system in relation to wells, buildings,.etc., can be placed-on reverse side). - ,1 <br /> FOR DEPARTMENT USE ONLY <br /> -daa- <br /> - <br /> T PTSD BY -- _ _ -- . _ DATE __r 37----.j. $/ <br /> REVIEWED <br /> APPLICATION ACCEPTED <br /> BY--------------------------------------•-•--- ------- ------------------------------------------------------------------------ DATE---------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------” € <br /> Alterations and/or recommendations:----------•------------------------------ --- -------------------------------------------•---------------------------- --------------------------------- <br /> I <br /> v <br /> ----------------------------------------------------------- --- ------------- ----------------•-----------•----------•----------- 'I------------ <br /> ,I <br /> / l <br /> FINAL INSPECTION BY:._-- :.C% ----------=-------- <br /> SAN' OAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxellon Ave. 300 LA/Rst Oak Street 124 Sycamore Street 205 West 9th Street, <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> CS 4 REVIS£G B-59 3M 3-'63 F.P.CC. a I� <br /> r <br />