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� FOR OFFICE:USE- ^ �- <br /> lf, <br /> 4 ______________ '. APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> If <br /> -------- --- - ------------- --------------------------- <br /> (Complete in Duplicate) <br /> Date Issued <br /> -----------------------"-..___.__-------------------- iThis 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. <br /> This application is made in compliance with County OX:Z <br /> ' 49. <br /> . <br /> JOB ADDRESS A D LOCATIO ..�-IJ"""�--------- ------ -------------------------------------- <br /> Owner's Name--"" �.------- ------------- -------------------------------------------------------------- <br /> ---- ----- --------------- ---------------- ---------Phone-------------------•--------------- <br /> Address ------------------"•-----•-------"-------------------------•-•----•-""-----•-------------"------"----------------------•------------------ <br /> Contractor's Name----- �----------L7 -------------------------------- }-------------------- Phone---------••-----. -.-- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ . Trailer Court ❑ Motel ❑/ Other ❑ <br /> Number of living units: /-"_"" Number.of bedrooms j---- Number of baths ---�-- Lot size -A--_--�1 6 <br /> Water Supply: Public system ,❑ Community system ❑ Private Depth to Water Table -- --At. <br /> Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No . New Construction: Yes ❑ No FHA/VA: Yes ❑ No I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi a k: istance from nearest well---_---_-------_Distance from foundation--------------------Material__..-----_----- ------.----..:.--------. <br /> o. of compartments ---------`,---��----------Size------------------- -------Liquid depth-------------------------.Capacity-----------•---------- <br /> Dispo a ieldj Distance from nearest well--(P-0_( Distance from'foundation-61 (Distance to nearest lot line--Z3� <br /> P�� Number o£ lines.--.__, _"""""" Length of each line-4724--o------- of trench <br /> Type of filter material___"" p c-f Depth of filter material-l8' -.--_----,Total length-,-?O._`"�--"�0-"f------ <br /> r <br /> ---_ <br /> Seepage Pit: Distance-to nearest well----/_-Q_0----------Distance from foundation""70"""._"_._. <br /> Distance to nearest lot line"�--- -_ <br /> Number of pits------I--------------Lining materiaC-7j .a.5;:t....Size: Diameter.-_.33-. ----_Dept h------ -- <br /> Cesspool: Distance,from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> F] Size: Diameter--------------------------------------Depth-------- --:---------------•----- -----------------Liquid Capacity---------------------- -:--gals. G <br /> Privy: Distance.from nearest well-------------------------------------------------Distance from nearest building--------_--_-- __----___-----.---------- <br /> ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------...... ----------------- 3 <br /> Remodeling and/or repairing (describe):--------------------------------------------- ---------------------•-------------------•--------------------------------------------- --------- N <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------------------------------"----_--.--_--_-_-_-----_-_----_---_--_--_-_-_---_-_-____---__------_--__.-_--___-------_________-----.-___---____---__----.-----_-------_--_.-__--__.------- <br /> ------------------------------•------------"--------------------"--•-----------------------....._----------•----•'•-------'-----"---------------:-------------------------------------------------------------- "._-.........- <br /> I hereby certify that. I have prepared this application and tho the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of t San Jo 16in Local Health.District. <br /> {Signed} -------------------------- (Owner and/or Contractor) <br /> B (Title) x <br /> Y•------------------ --------------------- - --- ---- -- -u---------------------- <br /> ---- --------------------------------------- <br /> (Plot plan, showing size of lot, loc relat to wells buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- % ---------'------------------------------------------------------ DATE----- - Z-4 Qr---------------------- <br /> REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------- DATE-- ---------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------- -- --=----------------------.... DATE------ ----------------------- ------------------ ------ -. <br /> Alterations and/or recommendations:--�'-S'--.4P4 !--- tc� <br /> 1 ISS - <br /> = Sa_5-..---•------------------------------------------------------------------------------•----•-----------•---•----------------------------------------------------------- <br /> --•-------••--------------------- ------------ -----------------------•-------•---------------•----•---------- --------------------------------- ---------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:.. Lii-' 1 Date- 3.... . . - - <br /> - --------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISFO 8.59 31A 3•'63 F:p.CO. <br />