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F!OR OFFICE USE: �` \ <br /> ------------------ <br /> ---- --------- - APPLICATION FOR SANITATION PERMIT Permit No.------------- <br /> - - - /r (Complete in Duplicate) € <br /> or f }. Date Issued . .___.______' <br /> „ate Issued ---------------------- <br /> Application <br /> �- <br /> i This Permit Expires 1 Year From D �� <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 Ordinance ,No. 549. <br /> S 3 �lct�oti-- <br /> JOB ADDRESS AND LOCATION:...--•------- ------ --- •-•--- - -`-------------------------------------------------------------.------------------------------------.... <br /> Owner's Name �#�'Vacw <br /> Phone <br /> ---••----- - � = <br /> Address--------A.Ar-171: 2>1 <br /> -----------�1 <br /> Contractor's Name----'.C; - -------- -------------- Phone---•------ - <br /> Installation will serve: Residence lEA—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of,living units: _�____ Number of bedrooms ._�17Number.of baths ;11.b__'�S-._�. _l-------------------------- <br /> I .._..Lot size ___ <br /> i k / <br /> Water Supply: Public system ❑ =.Community system rivate ❑ Depth to Water Table .{+_O ft. I <br /> Character of soil to a fdepfh of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Z--"Flardpan ❑ <br /> Previous Application Made: (If yes,date___.___..;-.,--------I No �New Construction: YesIET'�No ❑ FHA/VA: Yes [4`1lo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> n <br /> Septic Tank: Distance from nearest well:-- ---_--.Distance from foundation___j-P__r_____._.Mat <br /> ------------------ <br /> Septic <br /> of compartments_.._:_v".L_________________Size_Jd.'_�' .-->f- �_ Liquid de th_____ R <br /> ' __._Ca aci -Q 4 <br /> Disposal Field: Distance from nearest wel(___----__----Distance from foundation--------------------Distance to nearest lot line------- <br /> [ � Number' of lines_____1_s�Z_______________.___'Length of each line_ ---------Width of french.__ 4_'------------------------ <br /> Type of Cter.mmaterial�Crl�____.__-Depth of filter'material_L8-_°`_____________Total' length___f�"A__�____________ <br /> - ------------- <br /> Seepage Pit: Distance to nearest well---- _----IDistance from foundation---ZQ_f_--_-___.Distance to nearest lot line__a�--------- <br /> Number of pits__ ----------------Lining materiaI____t?b(A-r ---_..Size: Diameter---,x,3,3 ----Dept h---2x"__'_---------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_____--_____._ <br /> ' <br /> - -----.Lining material---------- ------------------------•- <br /> ❑ Size: Diameter-------- --- Depth----------------------------------------------------- <br /> --------------- =----------------------------------Liquid Capacity-.--------------------- --:-gals. <br /> I <br /> Privy: Disfance frominearest well________________--------------------------------Distance from nearest building.:___________________________._-..____._. <br /> [❑ Distance to nearest lot line------ ----------------------------------------------------------------•-----------------------------=-------------------------------------- <br /> Remodelingand/or repairing '(describe):--------------------- ------------------------------------------ --------------------•----------------------------------------- ----------------- <br /> ----- : -------•--------------------------------------------•--------------•----------------------- <br /> i <br /> , . t <br /> I hereby certify that I have prepared 4hi4 applicatibn and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, artderules,and reg lation of:ahe San Joaquin Local Health District. <br /> } <br /> (Signed) _____ __ ____________________ __ _____ ---_Owner and/or Contractor <br /> s <br /> o <br /> t, BY �..... '----------------------------------------------------(Title)--------- ------------- --- ------ <br /> (Plot plan, showing size of lot, location of system in relation-to wells, buildings, etc., can,be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ - <br /> Q ---------------------------------------- DATE-------- ----------------------- <br /> REVIEWEDBY---------------------------------------------------------------------------------------------------- ---•- ._..__.._--.--- DATE----- - --•-- <br /> BUILDINGPERMIT ISSUED--------------------` ------- --------------------------------------- DATE.----------------------------------------=------------------- <br /> Alterations and/or recommendations:__--_. ._3�j.-l? _C�-� -_-� __�� ______________________ _______ <br /> ---------- -------- -------------------------------------------------%.­----------- ---,-------------•------------------------------------------------------------------------------------------------------------------••-- <br /> ---- ------ <br /> Date <br /> FINAL INSPECTION BY:----- - -� --- --- -�- --- � - -�--�-.�:a............................---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVIS£O 8-59 3M 3-'63 F.P.CO. I <br />