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FOROFFICE USE: <br /> f----------------------------------------- --------------- <br /> ------- ---------------------------------------------- <br /> ---------•---------------------------------------------------------".. APPLICATION FOR SANITATION PERMIT Permit No. ..f J a-- <br /> {Complete in Duplicate) <br /> ----------------------------------- <br /> ---------------------- This Permit Ex ires I Year From Date Issued Date Issued ........ ._._. <br /> Application is hereby made to the San Joaquin Local"Health District for a permif to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance .No. 549. , <br /> JOB ADDRESS AND LOCATION_-__ p� � 5'y1�... a/J _U.id! �'lriV - , •-`- - -�� <br /> �� - - <br /> Owner's Namekf/k:./.C�- /YA- - —- ----------------- ------------------------------------- Phone <br /> - 7 .....r . ..... <br /> Contractors Name______________/f/_ <br /> Address.... -- ° -�- <br /> y l c _. Says!------ ,D��c�-_../.�4° P. �C'.,_- �' -- Phone.✓t ''.:f�c?! ,f.:%' <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> E' <br /> f+ <br /> Number of living units: J____ Number of bedrooms _-. Number of baths J____ Lot sizeXAy-e------.<,- -e......... <br /> Water Supply: Public system ❑ Community system ❑ Private OR Depth To Water Table -� ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam® Clay Loam ❑ Clay ❑ Adobe❑ Hardpan-C] <br /> Previous Application Made: (If yes,date--------------------) No ® New Construction: Yes ® No ❑ FHA/VA: Yes 0, -No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> 1I '_ (No septic tank-or cesspool permitted if public sewer-is available within 200 feet. <br /> ` 1 P J' <br /> Septic Tank: Distance from nearest well_.- -�._..._.,® compartmentsX Distan�c from foundation__-_I n_._.__-_.Material-_ <br /> -------- <br /> Disposal Field: Distance from nearest well-_8 �.__-,-Distance frM fo dtion---a9----------Distance to nearest lot line_________________ <br /> ® Number of fines______._...__ -- ._____�_Length of each liVe______4?Q_______________Width of trench.__a.y .._ ......___� <br /> li <br /> Type of filter material__ ___ - ji__De th of filter material= .._..��:`: Total long+h__r :`_: -l�_�_.__.. <br /> YP ��- P_ <br /> Seepage Pit: Distance to nearest well----- __-__�D+ante from foundationT............. .Distance +o nearest lot iine._._.___TR:e:) <br /> ❑ Number of pits--------- -----------Lining material-----------------------Size; Diameter-------•--- _---------.Depth-:----------....._._....--------- <br /> 3 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation__------------------Lining material-__'C_._--._---_________.__---_--___- v � <br /> ❑ Size: Diameter'=-----------------------------•----Depth----------------••---------------------------------Liquid Capacity-------••-•-• _ ---gals: <br /> Privy: Distance,from nearest well------------------•-•---•-----••------::---------Distanc6 from.,nearest-bUildin __--_______..__._----____----_--------. � <br /> - -, <br /> i �I❑ Distance to nearest lot line - = - <br /> -------------•---------- ... -�- ----------. ------------------------------------------ <br /> Remodeling and/or repairing (describe):""---/V ----- C��}1 ... /y`---- QJY11f1�'---•-CJJ/,(-----._/ j-v------------------ <br /> ----------------------- ---------;;-------•------------ ---------•----------------------------•----------------•--------------------------------------- <br /> ---------------- <br /> -------------------------------------------------------- _. .--------------------------------------- <br /> - ---------- <br /> -----------------------------------------------------,,-'------I---------- <br /> i: I hereby certify that.d have prepared +his application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br />' p4 '''--------------- --------------------------------------------------------•-------- <br /> (SignedJ----4�--�.---�--- --•- �d - -_=:--.-(Owner and/or Contractor] <br /> ----------­-­---------L <br /> a �- / �.,���( <br /> (Plot plan, showing size of 0 , of�sysfem in relation to wells, buildings;`etc.,^can be plbced�on reverse sideL�""' <br /> FOR DEPARTMENT USE ONLY <br />' <br /> APPLICATION ACCEPTED �`- - -----_'v'L-- ------------ DATE----- p •=.1 .� c <br /> REVIEWEDBYE`--==-'------- -- ------­------------- ----- ----- ---------- ''-=--- -... -------------.-• DATE <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------- •---------------------•-• DA•TE--------- <br /> AFFsrations and/or recommendations:-----------------------------------------------------------------•---=•-- <br /> --------------------------------------------•--•------------------------- ------------------- -- -----•-------- ..------•-----------•------- <br /> ---------- --•---------- •--•------•------------------•----------------------- <br /> ----------------------- ---•--------------------------•-••---------- ---•------------•------------ <br /> FINAL 1NSP Date <br /> ....../-� <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j! 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California 1 <br /> ES 9 REVISED a-59 2M 5-62 ATLAS 'I <br /> i <br />