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1-UR OFFICE USE: <br /> ------------------- ---- ------ - _ <br /> ---------- ------------------------ -------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. . .........�• <br /> - - -- '------------ <br /> -..- <br /> S _ � (Complete in Duplicate) 1 ZIP <br /> TP1is Permit Ex fres 1 Year From Date Issued Date issued"________________ <br /> Application is hereby made Offit 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 Ordinan� o549. # Ml�}1d `r�C"f� <br /> Ni Si I) t <br /> JOB ADDRESS AND '.LOCATIONV-_ 1_ e-d :C <br /> Owner's Name j— _ ,f >}i�" W: <br /> Owner --------V's _. <br /> Address----------- r; -.y_� Adav <br /> I€ ---- one----------------------------------- <br /> --------------------- <br /> -----------�----•--------------- <br /> z�-� 1 ?_/ N. -------------- --------------------- <br /> Contractor's Named l 'I1C -. a ----------------------_----- <br /> I = ,� -----•---•- Phone.. <br /> Installation will serve: Residence ,,Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel❑-I Other <br /> Number ofli�ng units. jlf-{Number of bedrooms � Number of baths __1__ Lot size <br /> -------------- <br /> Water .supply: Pu bli.c jsys+em 1 Community system ❑ Private Depth to Water Table 1-- ft. <br /> Character of soil 4ol-a depth of-Aeet: Sand Gravel ❑ Sand Loam ClayLoam Clay <br /> Previous Applica}i � � � y ❑ ❑ Y ❑ Adobe ❑ Hardpan ❑ - 1 <br /> n�Made: {I-yes,date---------. ] -Q '�'"� �! <br /> � New Construction: Yes �No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> ;Lr(No_septic }arlk+lor cess aI-permitted-if public sewer is.available-within 200 feet.)_ <br /> Septic Tank: Distance from! nearest well_ ______________Distance from foundation--------------------Material____---------------------------- <br /> F.)(M-n+11C-x-•- No. of com a.rtments---------- ---------- Size----------------------I-•--------Liquid depth- - ------------ <br /> ------- <br /> ------" <br /> I?' f + ----Capacity- ---------------- ; <br /> Disposal Field: Distance from serest well .? --.---.Distance from foundation____: - " <br /> ___.-_-DIs#ante to nearesT 'lot line_._—T10 <br /> — <br /> E. 1�T`i [t Number of lines-1 ` �(----- -- -_----Length of each line-------110-a---------_-_Width of trench__- -.2y 11 fi <br /> F <br /> T 1 e of filler materialdfC � _-_Depth.of„filter,material__ - Total length�______________10 <br /> Seepage Pit: Distance to nearest well----- .from foundation________- <br /> � ________..Distance to.near2st lot line________________ <br /> ❑ Number ir of4Pit------------- ------Lining'-rrnaterial----------------------.Size: Diameter------------ -.�__.Depth � <br /> ---------------- o <br /> 1 Cesspool: Distance from nearest well______-_-------D tante from foundation____________________Lining material.-_____. <br /> Y ----- <br /> ❑ Sizze: Diameter- Depth's == UquiA Capacity----------- <br /> gals. <br /> Privy: „„ Dis#anee�from,ne rest well_______________________..---- `__---_---_Distance from nearestbuildin <br /> g -------------------------- '`' <br /> ❑ Distance to nearest lot line ---------------------------- " +a •---------------•----------------- <br /> - ---------., .yn <br /> ------ <br /> Remodelingand or repairing describe :_---_-.---_____._ _____.__-_-- j <br /> W1. ----- <br /> t ----------- <br /> ------- ---------------- <br /> ------------------------ --------------.-- <br /> - Q1-- I <br /> ordinances, St Paws, and rules and red this ns oli atioSan Johat ih; 'Wo � - - - ---- - s <br /> F "es, certify that ! have r The worC;;wiii be done in acro ante with�San Joaquin County <br /> g Local Health District, <br /> (Signed)_1L <br /> ----------- <br /> --------------------------------------------- -_ ----------- --------------- ----- (Owner and/or Contract <br /> �.....�. o or) <br /> Y"--�=---�=-=---• -----•------ <br /> --------- =�= ' ---_---�-•=�'--—'__.• - _ _. _ . Title <br /> (Piot plan, showing size of.lot, location.of.system in relation to wells, buildings, etc., can.be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------+__RCz------------------------------ <br /> t K <br /> ------------ DATE----- �� ^ _-_ . <br /> REVIEWED BY------------=--•--'----- -- ,----- - I <br /> --------------------------------------------- - DATE--------•---------------------- <br /> BUILDI-NG­PERMIT-I-SSUED______ ----------------------- <br /> -- _-- -.;_ DATE_" <br /> Al+eretions and/ar recommendations:._ <br /> ” ` <br /> ---------- ----------------------------------- ------ 'C--'--------- ''1 s.3 [ -.---- ' ------•------------ <br /> ----------------------------------- <br /> - -------------- - . ..... . ---•-------- <br /> ----------------------- <br /> FINAL INSP --------------- Date------ <br /> A19__-- <br /> ----------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street <br /> 205 West 9th Street <br /> 5foekfon,California Lodi,California Manteca,California <br /> Tracy,California y <br /> s ES 9 REVISED 8-59 3M 3-•63 <br />