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I <br /> fa <br /> FOR OFFICE USE: <br /> ...........�.. .................... <br /> IIAPPLICATION FOR SANITATION PERMIT Permit NO. <br /> S3 a <br /> ................................. ............. <br /> ............. .........................___........­ (lCornplefe-in Duplicate) Date Issued <br /> ... . .. ..... ......... ..I............ 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. 6-.T3 --67 0 —010 <br /> OCATION .. .. ... <br /> JOB ADDRESS AND ...... <br /> Owner's Name--------- .......... Phone---------------------------- <br /> Address..................... ------ ------ <br /> Contractor's Name-..... ... eo�at..to.;;r, ...... ................... Phone...... ........................ <br /> Installation will serve: Residence 21--'Apartment House 0 Commercial E] Trailer Court Ej Motel E] Other E] <br /> dc, <br /> Number of living units:,/----- Number of bedrooms -J._ Number of baths _?��of size ----- --- ........ ------�' ----- --- ---------- <br /> Water Supply: Public system E] Community system F1 Prjvate'[ff""`Deptk to Water Table ------ - it <br /> Character of soil to a depth of 3 feet- Sand E] Gravel L], Sandy Loam E] Clay Loam El Clay El Adobe El Hardpan V), <br /> Previous Application Made: (If yes,date__..__ ......... ) No 0 New Construction: Yes E] No El FHA/VA: Yes E] No F] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: fh <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic nk: Distance from nearest well...5_41.......Distance from founclafion_..__!p_........Material .......----------- <br /> ............ <br /> No. of compartments....... Size-z"A..q. Liquid depfh....Zl- Capacify_.19..�10�. <br /> cisposfield: Distance from nearest well..--. Distance from foundation---- .......Distance to nearest lot line_.--.......... <br /> ii Number of lines........../.....................Length of each line.- .. ...Width of <br /> Type of filter material..... Depth of filter maferial__..�f............Total ............................ <br /> /Pi, <br /> eepa <br /> Sif: Distance to nearest well.. . Distance from Distance to nearest lot line.:4_ <br /> P <br /> FA lNumber of pits--------__/-------Lining material....... Size: Diameter.....1�...........Dept�--- .................... <br /> Cesspool: Distance from nearest well.-------------..Distance from foundation..... ...... .... . Lining material.........._-............._.___.___._ <br /> N <br /> Size: Diameter. ........ ....&apf h....................................................Liquid Capacity.... .......A......gals. <br /> Privy: Distance from nearest well...-__............................. Distance from nearest building............,.............._...___........ <br /> ❑ Distance to nearest lot line ........................................ .......................................................................... <br /> ............... <br /> Remodeling a"4#==mwer-"g (describe):..... ------ �-------­----------------------------------------------------------------------- <br /> 0 ............ ............... ......I................ <br /> ------•----•---------------------------------------•--•- ............­­­­......I——.. .. ...................................................... ........ <br /> .................................................................................................---------------------------------------------------------------------------­-------------------------------------------- <br /> -------------- ---------------........................ .•-----. •-................................................... -------- ---- --...............-------------------------------------------------- <br /> I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, ate laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)._- ...... ............*............ ------ -- -------- ------*---------- ---- -- ---------- -_=FG=r_ and/or Contractor) <br /> By:.-._.Ava - ----(Title)---------- _ --- --- -- <br /> - -- <br /> (plot plan, showing size of lot, location of sys; r-e-l-a-fi"on o__wells,ells,__buildings,, __etc.,__can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> .................... DATE....11713�- 7-_----------------------- <br /> APPLICATION ACCEPTED -------_............... -------•----- <br /> REVIEWEDBY............. ..................................................................................................... ........ DATE---- . ................................................- <br /> BUILDINGPERMIT ISSUED........ ....................................................-----------------..................... DATE................................ --- ------------------------- <br /> Alterationsand/or recommendations:---.................... ........................... .............. _----....................... .................................................. <br /> ..:.........._....-------------••-----------------------------------------------------------------•--•--.-...---..--.-----._.-.-.................... -•-- --._................ --------------------------------------- <br /> ..........................------..._--......._..----••------•.........-------------------------------------------------------------------------------------------------------------------------------------- <br /> ..y.................................................................................................. ...................................................................._......... ............................... <br /> .................................................................................................. ----- ----------- ----- ----- ------- -------------------------------- <br /> ------ D ate// .............:FINAL NSPECTION ............. ............ ...... .. <br /> I. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haisphan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,Callfornra Lodi. California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vongvard Press <br />