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FOR OFFICE YSE: "` ✓ <br />----------- ------------------ ------ ---------------•--- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ..� '�1�__._�_ <br />------------------------------ -------------------------- (Complete in Duplicate) Date Issued _._.._.�f/2--...�_7 <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. i <br /> This application is made in compliance with County Ord• ante No. 549 <br /> JOB ADDRESS ANDALATEN/- _ �Owner's Name----------- ---------- - ----------- ----- ---.-- Phone)( <br /> Address....................... ------ ----------••••-•---•------------------------------- <br /> �L/� �� � �1 .� Phone........... <br /> Contractor's Name............. <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other �n� <br /> Number of living units: ........ Number of bedrooms -------- Number of baths ________ Lot size .._11. - ------- .. <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ........ ft <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHANA: Yes ❑ No ❑ <br /> TYPE INSTALLATION AND SPECIFICATIONS: <br /> o septic tank or cesspool permitted if public sewer is available within 204 feet.) <br /> S Ic Distance from nearest well_________________Distance from foundation-------------------Material................................................. <br /> No. of compartments------------------------•-Size--------------------------------Liquid dept---------------- ---------Capacity--•-----•-....�....-f <br /> osa ieJd: Distance from nearest well_ti.QW- -Distance from foundation---f--J_ ----Distance to nearest lot line..... <br /> Number of lines --------- Length of each line----j _0--- ------Width of french--------C.01-q_r•--••------- <br /> F;} Type of filter material..SRc__ Depth of filter materiaL__. !__.Total Iength.....�.QQ�........................ <br /> a Pit: Distance to nearest we -______ --- from foundation____________________Distance to nearest lot line.................. <br /> g � V <br /> Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth................................. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------------------—...... <br /> ❑ Size: Diameter--------------------------------------Depth--------------------------------•------------------_Liquid Capacity----.....--•---------------gals. <br /> Privy: Distance from nearest well---------------------------------- _____"-Distance from nearest building.--._-________-_____-_--------_--______._. <br /> ❑ Distance to nearest lot lin ---------••--•--------------------------------------------------------------------------------•-•--•-------------------•-------------. <br /> Remodeling and/or repairing (describe ------------- ---- ----- ---- _.._.......---------------------•-•-•----------------••-•---..._---------. <br /> .........---••---------------•-----------...--------------------- ----- -••------------�- .--.---.-------- ----------- x <br /> --------------------•-•---------------------------•---------------- ------.....---- ....---•--•--------•-----------•-------•-------------•------..............---------------------------------..------------------------- <br /> , <br /> -------•---------------------------------------•-----••----• ----------------------------------------------------------------- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County- <br /> ordinances, State S. ules and regulati s of the San Joaquin Local ealth District. <br /> T, <br /> � ontrector <br /> -- ----------------------[Signed) n ) <br /> BY:----------------------------------------- --------------- ------- ----- --- --- ---------(Title)----------- -------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation wails, buildin (et ., canbe placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- ---- �{� DATEe' ` <br /> REVIEWEDBY-------------------------------- --------------------•-•-----------------------=------------ DATE__. •---•-------•------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------.----------------- --• DATE------------------------------------- ----------------- <br /> Alterationsand/or recommendations-------------------------------------------- -------------------------------.._........---------------------------------•--------------------------------------- <br /> -------------------------------•-•------------------------------------ ------------------------------------------••----------------------------------•----- -----•-------•-----------------------------------------------•--- <br /> ---------------------------------- --------------------- ----------------------- ------------------- --------------------------------------------- ------------------------------------------------•---------....... <br /> FINAL INSPECTION BY: ----- Date. L-� <br /> -- <br /> -----••-• ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED 5.59 2M 5-6I AILAS <br /> t <br />