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FOR OFFICE USE: IN <br /> --------------------------- � /,) �0 2, <br /> APPLICATION FOR SANITATION PERMIT Permit No- -- _- -- ----------- <br />--------------------------------------------------------- <br /> ----------- - -------------- - ----------------- ------- (Complete in Duplicate) Date' Issued <br /> ------------------------- This Permit Expires 1 Year From Date 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. <br /> ------- <br /> JOB ADDRESS AND LOCATION---------------- 7------- ------- -------- / -------------• ---- -- -•-- ---------------------- <br /> 3_ ; C, Phone---/ ------- <br /> --- ------------ ------------- <br /> Owners Name-------------- .............. . . .....7�------------ 6L/ <br /> Address............------------- ------- —------- ....... <br /> Contractor's Name------------- -__4,— ------------------------------ Phone-----------------------_ --------- <br /> _,;�---------- ... ....--------------- <br /> Installation will serve. Residence [] Apartment House [] Commercial 12it Court E] Motel E] Other <br /> 10I Z j- _,�- e - ----------------- <br /> ;e,4 -- <br /> Number of living units: -------- Number of bedrooms -------- Number of s �9 <br /> ., Lotsize ---------------------Ir ----------------- <br /> Water Supply: Public system El Community system El Private Z Depth to Water Table _90 ft. <br /> Character of soil to a depth of 3 feet: Sand P Gravel [] Sandy Loam F <br /> ] Clay LoamjK Clay E] Adobe F Hardpan ❑ <br /> Previous Application Made: (if yes,date.- No F-1 New Construction: Yes [] No [X FHA/VA: Yes F] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Serjpk ------------------------------------------------ <br /> ,pi4z,rice from nearest weh-----------------Distance from founclat'on-------------------Material <br /> -N/. of compartments--- ---------------------Size-----------------7---------- ---Liquid depth----------------- --------Capacity----------------------- <br /> Disposal Fiel <br /> -------Capacity----------------------- <br /> Dis Distance from nearest well-------1177-a--Distance from foundation-._---1-o-_---.Distance to nearest lot line-------� -0 <br /> Number of lines---------------/.---------------Length of each line ....Width of trench------------ :f--------- <br /> Type of filter material----.-_-- --Depth of filter _...---,_Total length-----------------=__!r!------------ <br /> -0II? <br /> 3 -- <br /> Seepage Pit: Distance to nearest well----------------__-Distance from foundation---_____._____---- Distance to nearest lot line----------------- <br /> ❑ Number <br /> ine----------------- <br /> Number of pits----------------------Lining material---------------------- Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation...-----_--.-_----.Lining material-------------------------------------- <br /> F-1 Size: Diameter------ ----------- --------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--------------------------------------- ---------Distance from nearest building-----._.---------__--------_---.--_.-_.. <br /> ❑ <br /> uilding----------------------------------------- <br /> F1Distance to nearest lot line-------------------- -------------------------------------------------- ---------------------------------------------------------------------- <br /> ------------ <br /> Remodelian and/or repairing (descx1LL_ -------- --- --- ------------- <br /> -------- ---- ------- --------- - ----------- -- --- <br /> - ----------------------------- ----------- <br /> --- ---------- JI-6 <br /> ----------------------------------------------------:,��---------------------------------------- ----------------------------I------------------------------------------------------------------------------- - - <br /> I hereby certify that I have prepared this application and that the work will be donee accordance with San Joaquin County <br /> ordinances. State laws, and rules and regulations of-+he San Joiquin Local Health District. <br /> 4- (Owner and/or Contractor) <br /> (Signed,------------------ ------- ------------------------------ ------------------------------------------------------------------ <br /> _W I 1 ------------------------- <br /> (Plot <br /> -1.... ---------- <br /> By:---------------------_--------------------------------------------------------------------------------------------------------------(Title)--.-' -------------------------- <br /> (Plot plan, showing size of lot, location of system in relation*fo wells, buildings, etc., can be placed on reverse side). <br /> FOARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------- ------- ---------------------------------- DATE--------------11 1-YA-3------------------- <br /> ��j DATE------------ ----------------------------------------------- <br /> REVIEWED BY------------------------------------------------------- ----------------- ---------------------------------------------------- T <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------- ------------------ DATE------- - ---- ------------------------------------------ <br /> Alterations and/or recommendations:------ ------------------ - ------- ------------------------------------------------------- - - ----------------------------------------- <br /> A, ------------------------------ <br /> --------- -- L) I <br /> ----- -------- <br /> -- - -- ---------- . ..... <br /> ------ ----------t--- - - ----- -- <br /> --------------- ---------------- -------------------------- --- ------------------------------- -------C�----------- --------------------------------------- <br /> --- --- -- -- - ------------------------------- <br /> ---------------- ------------------------- ----------- ---------- --- <br /> - -- <br /> -----­------- --- -- - --------------------- ------------ -- - --- -------- ------------------ ------ --0--------------------------------------------------- <br /> ---------------------------------------------------------------- <br /> ------------------------- ---------- --------------------- - ------------------- <br /> - -------------------------------------------------------------------------- <br /> FINAL INSPECTION BY------ - ---------- ----------------- Date_ <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazatton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES .0 <br /> 9 REVISED a-S9 3M 3-'r3 F".// <br />