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FOR OFFICE USE: ' <br /> -------- <br /> �>/ 6 "APPLICATION FOR SANITATION PERMIT <br /> ---- -- <br /> -------------------------- _ - ------.--- (Complete in Duplicate) <br /> This permit Expires 1 Year From Date.Issued i Date Issuedf- -#- <br /> __ <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 /> JOB ADDRESS ANDjLOCATION---------------------------------- -------- <br /> --- �- n ----------------- <br /> ----------•--•----•- -------------------- - - -------=--------------I-- <br /> Owner's Name----- ----`----�--,-, � --------_ Phone------------•---•---••-------------- <br /> Ad d ress--------------------------- <br /> Contractor's Name-•- ' ------ro .�l'Z_S - --- • -•---------------•----•--•----•-----.--_------------------10 <br /> .. .. . :.. ............ Phone <br /> r� �h <br /> Installation will serve: Residence �j Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other El <br /> Number of living..units:.__j__ Number of bedrooms -_.t. Number of baths _/____ Lot size:l�_ _:__ _ _____________ I <br /> Water Supply: Public system �mmunity system El Private E] V Depth to Water Table 'I _ ft. <br /> Character of soil to a depth of 3-fee t -Sand ❑ 'Gravel ❑ Sandy.Loam ❑ Clay Loam 0;!!Clay ❑ Adobe ardpan ❑ <br /> Previous Application Made: (I€yes,d#te._________ _______) No New Construction: Yes ❑ No FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND'SPECIFICATIONS:' <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi( ank:r stapf com arnea tst well---------------- Distance from foundation uid de th Material-._______._-___._--__________-________________- <br /> o.p <br /> P t � q P. Ili------------- Capacity-------------��-- <br /> Dispasal Field: Distance from nearest we -----------------Distance from foundation_�6________--distance to nearest lot line-<.5___________ <br /> [ � Number of lines_______._____________ ----------Length of each line_ _ ---------------Width of french-,1-�--.----__..____________ 1� <br /> _Type.of.filter matenai_'_%?_4C�C__.__Depth of filter material___ _ ___________�iltal length_.__.Fa_____--,__________/_____ <br /> Seepage Pit: Distance to nearest well_&_U____f <br /> ----------Distance m <br /> foundation__/�-f�___..Distance to nearest lot in <br /> e__s. __ <br /> ___-l <br /> Number of pits----1_1_----------Lining materia �C,4.Size: Diameter----�1_- -------- --�___-- <br /> Cesspoolmaterial <br /> 0 <br /> Distance from nearest well_________________Distance from foundation____________-__.._..Lining material_..____________________.____________. <br /> ❑ Size: Diameter----- ------------ gDepth--------------------------------- -----------------Ll�quid Capacity----------------------------gals. <br /> Privy: Distance from nearest well---------------______________________________`___Distance from nearest building____.___-_-__--____-_______._______._. <br /> ❑ Distance to nearest lot line-------- ------------- ------------------------------------------------ --------- ---------------•-------------------- <br /> Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------I--•-------------------------------•--------------------- . <br /> >i Ih <br /> -------------------------------------------------------------• -1-----------------------------------------.........._--...... ------••---------••----­----------lu---------------------------------------------------------- <br /> - --------------------------------------------------------------I------------------------ ----- II! --- <br /> 1 hereby certify tha+ i have prepared.this.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 /> {Signed} ------ ---- ----- ------ ------ -- ---=--- -- ------------------ ----------------------- ----•-- (6wrlsr�3"�rTtl/or Contractor) <br /> 9 II <br /> BY= ..- - - --- ------------ 4{Title} "" - <br /> (Plot plan, showing size of ot, location of system.in relation to wells,.buildings, etc., can be plil ed on.reverse side)..' <br /> i FOR DEPARTMENT USE ONLY { �� <br /> APPLICATION ACCEPTED BY- -Q+ ------------------------- DATEc=- F��--------------------------- <br /> REVIEWED BY-------------- <br /> ------------------------------------------------'------------------------ --------------------------------- DAT------------------------------- <br /> BUILDING PERMIT ISSUED---------------------------- -------------- �,z_ L DATE�p------------------ - --------------------------- <br /> Altera#ions and/or recommends+ions_Y w 1` =---------- �N---•------------------------------=---- •------------- <br /> -------------------------------•- ------------------ ------•---------- ---- ------------ -----------------------I--- ----•-------------------------------- ------------------------------•----------------•--------•---- <br /> --•-------I•-------•----- -------------------------------------•---------------------------------- ,. <br /> Y <br /> ____________--------------_---------------------------------------..-.-----__ <br /> ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ <br /> • . ..,.. ,: - a.r +..+miner----... . s�.e -.-- � r....r .. _..� J. �.�wa,rwP <br /> FINAL INSPECTION SY: = ------ Date �J - -- ----- ----- <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Nozellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REvisEo 9-59 �m 3-•63 F.P.rcj. <br />