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FOR OFFICE USE: <br /> -% -- ------------------- -- <br /> ----------------------------- .......... - <br /> -_______________..._-..........._.....__ ------ APPLICATION FOR SANITATION PERMIT Permit No. <br /> ---------------------------------------------- ......... (Complete-in Duplicate) ' <br /> ..... ..... ................ ...... . . ..... This Permit Expires 1 Year From Date Issued bate 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 Ordinance No. 549. "r W <br /> JOB ADDRESS AND LOCATION <br /> Owner's Name s - _C/ `--- - ------------------------------ ----- Phone----••------------------------------ <br /> Address-------------- <br /> ----------------------------.Address-------------- :f P.4;ize <br /> -----------�-�-•----------------------..-_..-•----------------------------------------•-•------ -••-------------------- <br /> •------------ <br /> .._.... <br /> Contractor's Name------ ._ �.r�_±'' --- ..-�WOe "_.__ <br /> -------------- <br /> Phone <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial E]'!--Trailer Court ❑ Motel ❑ Other [! � <br /> Number of living units: ._ Number of bedrooms _X. Number of baths._1K Lot size Z .f70#?t -------------------------------- <br /> Wafer <br /> - ---------------Water Supply: Public system ❑ Community system ❑ Private Vr�Depth to Water Table,440. ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay [] Adobe ❑ Hardpan ❑ <br /> Previous Application Made: [If yes,date.................w- I No ®-'New Construction: Yes @9-"No ❑ FHA/VA: Yes ❑ No 4P—"N% . <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: _ <br /> (No septic tank or cesspool permitted if public sewer is available wi4hin-200 feet.) ' <br /> t f <br /> Septic Tank: Distance from nearest well`'0r__Disfance from fo ndat'on... - .---___-__-. <br /> ----- - <br /> No. of com artments.. /� Liquid depth..f__-�_... .._.__.Ca pacitylZee_17---- <br /> Disposal Field: Distance from nearest well'-0106710..-Distance fromifoundation..1' 7..------.Distance to nearest lot line_,rev..._.-.- <br /> (�l Number of lines----_. ------ ... Length of each line_. 1 -------------Width of french,_ --.._-.-..._-__..........- <br /> Type of filter materia l Depth of filter material___, ------- Total length--- - - --.`--------------------- <br /> Seepage Pit: Distance to nearest well..... ................Distance from foundation-----.--------------Distance to nearest lot liner---.__-_-...... <br /> ❑ Number of pits..---------------- Lining material................. .. Sizes Diameter------------ ---w......Deptn-------------.---•--------------- <br /> Cesspool: Distance from nearest well ................Distance from;foundation _.._ ..Lining material-._____--------------.-___----------- <br /> Size: Diameter- ------------Liquid Capacity----------------------------gals. <br /> . <br /> ❑ -------------Depth <br /> Privy: Distance from nearest well.................................................Distance from nearest building._....------._______------------ <br /> ❑ Distance to nearest lot line--------------------- r----------s------------------------- ----------------r-------------------------------------------- <br /> r i <br /> Remodeling and/or repairing [describe): � y s.7iftr! ----•--------------------------------------------------•- <br /> ---------------------------•------------------------------ ----------------• "' <br /> u <br /> ------------------------------------------------------------ ---------- ---------------------------------- - ---- ---- <br /> ------------------- <br /> -- <br /> ------------------------------- ------------------------------------------------ ' Rio---- <br /> ------------------ <br /> -------hereby certify that I have prepared this application and that the work will be doccordance with San Joaquin County <br /> ordinancesr,State laws, and rules and regulations of the San Joaquin Local Health District. <br /> .� (Signed) -------------- - ------- -- --------------------{ +d or Contractor) <br /> By: / (Title).. -- ------ ----------- <br /> (Plot <br /> ---------(Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). - <br /> p FOR DEPARTMENT USE ONLY "1 <br /> APPLICATION ACCEPTED BY /C �.. - --------- ----- DATE---------2.--/` -6 ----------------- <br /> REVIEWEDBY------------------------------------ --------=---------------------------------- --- -------------------------- DATE----- __.-------------------- <br /> BUILDING PERMIT ISSUED-------- ------- ---------=------- ---------------------- --------------------------------- DATE <br /> Alterations and/or recommendations:------___-----..... - -- --- ---I..... ------ -------------------------------------------- ------------------- ---------•- <br /> -------------------------------------------------- ------ - --------------------- ----------------- ------------------------------------------ -------- ------------ _--------------------------- <br /> ------------------------------ - ----- ----------------------------------- - ------- ----------------- ---------------- ------------------------ ----------- ---- ---------------------------- <br /> 110, <br /> FINAL INSPECTION BY:..---- - Dafef' - - <br /> LOCA <br /> SAN JOA UIN L 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 /> E.H.9 2M 1-67 Vanguard Press <br /> s <br />