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FOR OFFICE USE: / t <br /> - ------------------ � 1 r <br />---------------------------- -- APPLICATION FOR SANITATION PERMITPermit No. <br />------- ------------------------------ <br /> ------------------------------------------------ {Complete in Duplicate) <br /> Date Issued _.--_. .1-----••.-- <br /> " _. _- -_-- - -This Permit'Expires 1 Year From Date Issued" <br /> Application is.hereby mode to the'San.Joaquin Local.Health District for a permit to construct and install the work herein descr' <br /> This application is made incompliance with County Ordinance'No. 549. <br /> JOB ADDRESS AND LOCATION- ---lal_7..---- -�=�s• <br /> ----- ----- -------- <br /> ' Phone. <br /> Owners Namer��-- ^-r--=- - -- - - ----- %•----------------•--- ------•----- <br /> Address------ l �Q ......GLS/A/ ------------- - •------ -------;•-•----- ----------------------------------------------- <br /> 41 <br /> ------•-•--------=------------------------- <br /> t`�>5 ,, ^_. , y ------------ <br /> p(� rr :-a Phone <br /> Contractor s Name-------/LD.I�-�-- ��--- <br /> -�""_ - .. <br /> Installation will-serve: Residence le`Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> � Number of living`units: _�--- Number of bedrooms _. Number of baths/Z_ Lot size .-"7.��?'�.l -----•- <br /> ,\yS F y 1. - - , <br /> i Water Supply: Public system ❑ Corn uriity system Wr Private ❑ Depth to Water Table - ft. <br /> Character of soil to a depth of 3.feet: I Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay❑ Adobe{Hardpan ❑ <br /> Previous Application Made: (if yes,date----------------------) No gal' New`Construction: Yes [ No ❑ FHA/VA: Yes No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:_ <br /> {No septic tank'or cesspool permitted if public sewer is available within 200 feet.) A <br /> Septic Tank: Distance from nearest Well ---— Distance fpm fou`0ation" -- Q-""._--.Mater l--- --4�-. --•----•• -- --------- <br /> No. of com artments-------- -----. 4W__X Liquid de th -- -- capacity Q ----.•--- <br /> p Size G p. �?�-------:-- P y--- <br /> i <br /> Disposal Field: Distance from n%earest well_.. ---------Distance from foundation__-�D_______--.Distance to nearest lot�ine----------------- <br /> Number of lines=F:_yX _T� �"�L� enngth of each line_� `C -�------------Width of french----- -__r-------------------- <br /> Type of filter rrsa`tenal- _ Fil1r,Depth of filter mate�rsaL_= -----------Total length-.-I�-_--------------------- <br /> ­ <br /> -- <br /> See ps a Pit: Distance to nearest well-__-"' ;_.-- __-D'sstance from foundafion____ 0._'....Distance fo*nearest lot line_3_------_.-.- <br /> Number of pits------- .----._----Lining material.-"4 0 4-*_-'Size: Diameter-_.-""-_- <br /> Depth3r 111 . <br /> Cesspool: Distance from nearest well-----------------Diiistance from foundation.-._"---._-.-------Lining material:_--.------.-----------.--.--------•- �i <br /> +` } --------Li Liquid Ca aci ------gals. <br /> •❑ Size: Diameter----- -- ------ ----- fil <br /> - =----••--;. p ----�---_.------- q p fY-�-----------------•- <br /> Privy: Distance from nearest well-------------------------------------------------- <br /> lot <br /> from nearest.building-___-"----'____--...---- <br /> �, <br /> ❑ Distance to nearest lot line- - --- ------- ---------- - --------•------------------- --------------- ------•------------------ <br /> y, '_�. ... ---------------------------------------------------------- <br /> Remodeiin and/or 're ,airin descris e :-------- /SCA/... ... <br /> 9 P 9 1 f , ;" <br /> -• ---------- <br /> } I ------ <br /> . <br /> r ------------- -•----•-- <br /> �_'_ --------------1----------- <br /> I�hereby'certify,thaf] hav'e;'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 /> ---------------� 4 - ` -------- or Contractor} <br /> / -'- -- - - <br /> (Signed} � dt�✓1�.�/1r------------ -- <br />` -_ -------•-{Title)--- <br /> (Plot plan, showing size of lot, location of sy m in`r. ation to wells, buildings, etc., can be placed on reverse side}. <br /> 1 a . � <br /> FOR'-DEPART <br /> USE ONLY <br /> DATE------ <br /> r �-- ----- --------------- <br /> APPLICATION ACCEPTED BY------ ----------- ------- ----:----- <br /> REVIEWEDBY--------- --------------------------------------------- ••----------------------- DATE-------- ---------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------- ----- ------------------------------------._ DATE------------- •---------------------------------------------- <br /> -------------- <br /> Alterations and/or,recommendations:-_--'--------------- <br /> ------ <br /> --------------- -- ---==--------------------------------------•-----------•--------------------------- <br /> -`: - �-� <br /> --;- -- ----------- <br /> -----. <br /> ------ ----------- =---------- -------- .------------------------- -------- <br /> =/ �e <br /> f72%' Date <br /> FINAL INSPECTION BY:.-W......C---r.---- �-�5 <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> 130 South American Street 300 West Oak Street ✓� - � "124 Sycamore Street, 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California TraCyr California <br /> E6.9 REVIBCD 0-69 r.P.CP.2M 6-6C - <br />