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FOR OFFICE USE: <br /> --------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------I- ---------- --------------- <br /> (Complete---------------- <br /> in Duplicate) <br /> Date Issued .... --- <br /> --------------- ----------- -------------------- This Permit Expires I Year From Date Issued <br /> NApplication is hereby made to the San Joaquin Local Health Dist rict for a permit to construct and iFs�a Vthe work herein descri <br /> 'This application is made in compliance with County Ordinance No. 549. <br /> 117 <br /> JOB ADDRESS AND ATiON <br /> 0,-5-0 Rev ------ - ------ ------ ----- ------------ ------------------- <br /> --------- -----V�--- <br /> - --- -------- ----- ----------------- <br /> Ow�ner's Name--------- -- -------- ------------------ - ---- ---------------------------------------------------- ------ --- ------------ Phone------ -- ------- <br /> Address -co -a6 I <br /> Address.......----------- -- --- - -- ----- -- --------- 2 <br /> --------­ --------------------------------------------- <br /> I----------------------- <br /> --- ------- <br /> r -------------------------- <br /> ,Contractor's Name-------- -- -------------- ------ -------- ------------------------ --------- Phonl%,i�OW/ !�_v <br /> Installation will serve: ResidentApartment House E] Commercial 0 Trailer Court E] Motel [I 'Other El <br /> ,5 Number of living units: 9 bedrooms --- Number of baths ---L Lot size __- ® -o---- <br /> Number of bed <br /> Wafer Supply: Public'system E] Community system C] Private Depth to.Water.Table/-P- ft. <br /> "Character of soil to a depth of 3 feet: Sand [-] Gravel F] Sandy Loam 0 Clay Loam E] Clay' ❑ Adobe [],.oH&rc1pan <br /> I <br /> te Previous Application Made: (if yes,date____-----------_ No E-] New Construction: Yes E] No FHA/VA- Yes F1 No E] <br /> e <br /> aa <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Tank:!ep tk: Distance from nearest well---------------Distance from foundation.___---_----- .- Material---------...---.---------...------..---..-.-----. : <br /> No. <br /> aterial------------------------------------------------- <br /> No. of compartments---------------- -- -----Size----------------------I---------Liquid depth------------- ------------Capacity------ -- ------------ 4S*, <br /> f <br /> Disposal field: Distance from nearest 'WeII_,-$_01__t_Distance from foundation---'!V A__'_._._Distance to nearest lot line/p!p <br /> Number of line's----�L----------I-- ------- -Length of each line-- --- Widt0of trench------- ------------- <br /> Type of filter material--5, --Depth of filter material------Ar!"--._.-Total iength---------------------45__ <br /> Seepage Pit: Distance to nearest-well---------- ------Distance from foundation--------------------Distance to nearest lot line----------.-----_ <br /> fy <br /> El Number of pits----------------------Lining material------------------O—Size-­Diametbr-—-----------1--------Depth----- ----------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---._--------_..____---__-__.._--. <br /> Size: <br /> aterial--------------- ---------------------- <br /> Size: Diameter---- ------------- --- ---- ----------De th-------------------------------------- -----Liquid Capacity- --------------------------gals. <br /> Privy: Distance from nearest wel ----- --------------------- ------------- -Disfance.from nearest building-----.--_--------__----_------..---..__.-. <br /> F1 Distance to nearest lot line-------- -------- - - ------------------------- ----------------------------------------- <br /> - -- ------------------------------------------------------- <br /> Remodeling and/or repairing (describe):.... <br /> 1 ----------------------------------- ------- --------- ---------------------I------ <br /> ------------------------------------------------------------------------------------------------- ---- ------------- ---------- ---- <br /> ti <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - -- - <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, S!f� ws, and rules and regulations of the San Joaquin Local Health District. <br /> Si ned ---------- ------- - -------6--------- ...... ---- wrier and/or Contractor) <br /> —-------0__�----- -- ---- ------------- ------------------- i <br /> be) � )0 - ., - ­_­----------------- --------- .......... <br /> BY:7-----------_----_-------- <br /> ----- ------- ------------------------(Title)-------V <br /> (Plot plan, showing size of lot, location of system in re oin'to wells, buildings,.etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> -1 - <br /> APPLICATION ACCEPTED 8Y----------------------_ <br /> 8Y----------------------_ 0- - s--- <br /> - -----/- -------------------------- DATE-----------•---- ------/------------------------- <br /> - <br /> REVIEWED BY------------ - ---- /.- - __ DATE------ -- <br /> BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------------------_--------- DATE------------------------------------------------------------ <br /> Alterationsand/or recommendaf ions:---------------------------------------------------------------------------------------------------------------------------------------- -------------------- <br /> -------------------------------------------- ---------- ------------ ------------ ------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------I------------------------------ ------------------------------------------------------------------ <br /> ------------------------------------------------------ ----_------------------------­---------------------------- ------------------------- ------------- --------------------------------- -------------------------------- <br /> -------------- ---------- --------- ----- -- ------------------------------------- ---------------------------------------------------------------------------------------------------- ----------------- <br /> --- Date------------------ -7C <br /> ---------------------- ------------------- ----------------- <br /> __j <br /> FINAL INSPECTION BY:............... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160i E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy, California <br /> ES 9 REVISED U-59 3M 3-'60 F.F.0O3 <br /> N <br />