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FOR OFFICE USE: <br />---------------------- <br /> ----------------------------- <br /> ------------ ---------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. .. .-----I�.--- <br /> (Complete in Duplicate) Date Issued <br /> /�- <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 hare' described. <br /> This application is made in compliance with County Ordinance NL�� <br /> 549Z7 <br /> JOB ADDRESS AN LOCATION.f --- .__ <br /> ray] <br /> Owner's Name----- u�� ----- �7. -------- ----- - ------------------ ------- -------- Phone. <br /> n�J L� 2 s(o J-�--t�ts -----•-•-----------•------------------- <br /> Address ------------------- <br /> . ................. ---- -------- ------ --------- ---•----- ----- ------------ <br /> Contractor's Name.------ r ------ Phone...................._------------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _1_____ Number of bedrooms _9".' Number f baths _-1___ Lot size __._. ` -._Q----------------------- <br /> Water Supply: Public system C] Community system El Private f Depth to Water Table <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-----------.........l 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 Tank: Distance from nearest well-----------------Distance from foundation__.__-/ 0------Material___________________ ___ ------ <br /> -_Size._ � S.1 Liquid de th__--__- _ Capacity F-* <br /> No. of compartments-------���------- � ,�..��-- - --- -- 9 P.� T------ -- P Y----Q- -- <br /> DispospI Field: Distance from nearest welL__�O_.-__Distance from foundation___.__�_d�__----Distance to nearest lotfline_-_S`____. <br /> [� Number of lines----------`.-_--- -_-- Length of each line______-�__�-----_-______.Width of french.__�_-_�___.__.---_.---_-___. <br /> Type of filter material_-_ !f t_-__Depth of filter material____. -�--�-______Total length_____rf__�_!�_________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation______-.._______--_.Distance to nearest lot line----------------- m <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- H <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> El Size: Diameter----- -------------------------------Depth--------- --------- ------Liquid Capacity----------------------------gals. <br /> ' <br /> Privy: Distance from nearest well _____________-----------------------------------Distance from nearest building-------------------------------------------- A <br /> ❑ Distance to nearest lot line----------------------------------------------------------------------- ----------------------------------------- ----------------- -- -- -� <br /> Remodeling and/or repairing (describe____________ _ 1 <br /> - ----------------------•----------------------------•------------------------------------------------•------- <br /> -------------------------------------------- -------•----------- -------------------- -•-------------- ------------------------------------------------------- -------------------------------------- --------- <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State IPNand rules and regulations of the San Joaquin Local Health District. <br /> - -------=---------------------------------------�nd/or Contractorl <br /> (Signed)--- ---------------------- -------- <br /> BY:----------- -- - - - ----- --------- -fin <br /> _ (Title)------------------------------------------ <br /> (Plot <br /> ------ ------------------------------... <br /> - - ---------- <br /> (Plot plan, showing size of lot, location of systeelation to Is, buildings etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- 1= r -------- ---------------------------------------- DATE-----. ." `3 -f5 - <br /> REVIEWEDBY------------------------------------------------------------------------------- ---------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------- -------------------------------------------------------- DATE------------------------------ ----------------------------- <br /> Alterationsand/or recommendations:-------------------------- ------------------------------••------------------------------------------------------------.---------------•-----•---_--------- <br /> -------------------•------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------I------------------------------------------------------I------------ =---•------------------------------------------ --------------- -------------------------------------------------------------------- <br /> FINAL INSPECTION BY:._ r^��_f. ll----------------- Date_--^ -� -- �- .G5' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hatrelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 3M 3-'63 F.P.CO, <br />