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FGR,iz Q OFFICE USE: <br /> ------------------ ------------------------------------- <br />- ------------------ - -- ---------------- ---------------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> --------------­-- -- --------------------- --------------- <br /> (Complete in Duplicate) I <br /> ----------- ----- ----------- -------- ---- ------- This Permit Expires I Year From Date Issued Date Issued ------// <br /> C7?_0 Z_ <br /> Application is hereby made to the San Joaquin Local Heal+h District for a permit to construct and install the work her In described. <br /> This appl icaf ion,is-made in compliance with County Ordinance No. 549, <br /> JOB ADDRESS AND CICATIbSt�__j <br /> Owner's Name------------ <br /> ---------- ---------- Phone Address------ �-7— --------- --- <br /> Contractor's Name----(4/A_L_X.E.ER,,---------------------------------------------- ------ ----------------------------------- Phone-------•---•----•----- <br /> Installation <br /> hone-----------_--------------------- <br /> W-------------- <br /> Installation will serve: Residence eApartment House [:] Commercial (Trailer Court F] Motel El Other [I <br /> Number of living units: ___II___ Number of bedrooms -3- Number of'bafhs _2-_ Lot size <br /> ----------------------------------- <br /> ---❑ <br /> Number <br /> Supply: Public system El Community system [] Private �_bepfh to Wafer Table J,_ ft. <br /> Character of soil to a depth of 3 feet: Sand 2""Gravel Ej Sandy Loam El Clay Loam E] Clay E] Adobe El H]ardpanEO] <br /> Previous Application Made: (if yes,date-------------------- No 0" New Construction: Yes [2-INZ El PHA/VA.- Yes 2 Nom <br /> TYPE OF INSTALLATION ANbSP`ECIFICXTI.0NS: <br /> . ;I 6h <br /> (No septic tank or cesspool re­rr;�itfed',if publies-eWris available within 200 feet.)-o <br /> Tank ff <br /> 5eptic Distance from nea�est Y411 <br /> an e-v rom foundation---./C-- <br /> X -A x/l, <br /> ist f _---.Mate <br /> b, No. of comp""artmen 7'6_2 _j �l <br /> ---------.--Size Liquid dep. -------- Ca pacify..../Zr_CJ_ <br /> Disposal,Field: Distance from nearest well-----'?C)......Distance Jorn foundation.../4"7-r------Distance to nearest lot line---- <br /> jo lea <br /> Number of lines-5----------------------------Lengthr-f each Iine_W_-_69-_,:�P-------Width of trench--93-1-/ 4- C 1, <br /> Type of filter of filter ofal lengfh---/-345------------------ <br /> -------------------C <br /> Seepagestance to nearest well_._ S0 '!DiA <br /> D; _`_!�-Distancf-'e from foundation---/0 ance to nearest lot line-----,7------- <br /> Number of pits----- ----........Lin ing-!-�haf j_riial Size: Diameter-5 --Depth------ <br /> III . 7b ---------- <br /> ------------------------- <br /> -.Cesspool: Distance from foundation -------------- <br /> Distance from nearest-��11--------------�-__Distance <br /> -----Lin'ing material___.___.__._._---_--___._Size: Diameter--------_1 4 ---------------- <br /> ---- ------r----------- -------- -i, id Capacity-- -------------------------gals. <br /> qu <br /> ;r <br /> 'Privyl Distance from nearest well-----------_A.� @�t <br /> 6. -----------------I------------Distance from nearest building. -------------------------------------- <br /> 6. Distance to nea"resf lot line.-.____--__- "'Ili, I <br /> ---------- ------------ --------------------------------- --------------- <br /> FRennoteling and/or repairing (de(cribe]:_//' V - - --- -�G_y <br /> _VV <br /> _LqS z �R <br /> _E <br /> `-0.-----•--•--------•--._____-------------------- <br /> F. <br /> ----------------------- <br /> --y----- . t d Illi A <br /> ---- - --------------------------------------------- ---------------I ------ <br /> rr_�- -------------------------------------------- ----------------- <br /> I hereby certify that I have prepared this application and that the work will be do"ne in accordance with San Joaquin County <br /> ordinances. State laws, and rul4s and regulations of the San JoaquinLocal Health District. P <br /> (Signed)----- <br /> - - -- ----------- - --- -- ------- -------------------_-------- --- -------- ---------- <br /> ---- ---- ----------(Owner. and/or Confractor)___�. <br /> BY- ----------------------------- <br /> ------------------------------------------------------------------- --------{Title)----------------- ------------------ ------- -------- <br /> (Plot-plan, shov4ng size of lot, location of system' in relation to wells, buildingsi0c:7-67"`011"wd on reverse side). <br /> can ace <br /> FOR DEPARTMENT USE ONLY,. <br /> APPLICATION ACCEPTED B' ------_7777 <br /> REVIEWED BY-------------- I. i------------------------------------------------------------ DATE----- .. ..... ..a__----------------- <br /> --------------------------- ------------------------------------------------------------------------------------ DATE----- ---------------------- --- <br /> BUILDING PERMIT ISSUED-----1 <br /> ------------------------------------------------------ DATE <br /> Alterations and/or recommendations:---- ---—--------- <br /> ---------------- ------0-(-K=----------- <br /> -ww'-C <br /> - ---- --- ....... <br /> T --------- ------- <br /> ----------- -------------------------------------------------- --------- - ---------- - ------- <br /> ---------- --------- --------- ------------------------------------------------------ <br /> -----n7 <br /> �SP TION BY:.QV <br /> FINAL INSPECTION <br /> ------ Date- <br /> -------- --------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton 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-69 3M 3-6.1 F.P.00. <br />