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FOR OFFICE USE: ti > <br /> APPLICATION FOR SANITATION PERMIT Permit No. ... ...--.? <br />-------------------- ---------------------------------- (Complete in Duplicate) 6Z"14�-5--Phis Permit Expires 1 Year From Date IssuedDate 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 /> 6 C� - - -----•-•---- ------------------------------------------•.---------------••-------------- <br /> JOB ADDRESS AND LOCATION _ __________ --"---"""-- <br /> Owner s Name------ - -- r � �--_--- ----...`.-..�..T- Phone=-.----•-••----•-••---------------- <br /> s <br /> Address- Q --------------------------'--------------- f <br /> Contractor's Name-------...0 < -- ------- Phone--------------------- <br /> - -------------- <br /> Installation will serve: Residence ®Apartment House ❑ Commercial �❑ Trailer Court ❑ Motel ❑ Other ❑ 1 <br /> Number of living units: ---I--- Number of bedrooms��Number of baths _4S_ Lot size ----- ,-----------------_------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private P�-`6epth to Water Table __. _ ft. <br /> Character of soil to a depth of 3 feet: Sand:❑ Gravel ❑ , Sandy Loam'E] Clay Loam ❑ Clay ❑ Adobe 0—Hardpan ❑ <br /> Previous Application Made: (If yes,date-----------.--------) No 9�—_New'Construction: Yes ❑ No 2-�­FHA/VA: Yes ❑ No [n' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available withinr200 feet.) <br /> Sep <br /> tic T : Distance from nearest well--it _R Distance from foundation:_:� '__________.Material__ '�* <br /> No, of compartments_..____ "- .. `E1 <br /> �. � . r <br /> _... #u Size X 'r g Liquid depth `+ Capacity7_ <br /> Dispo Fiel :� Distance from nearest well------.._. --_-Distance from foundation____________________Distance to nearest lot line----------------- <br /> p� � Number of lines ----------------- ----- Length of each line Width of trench. <br /> Type of filter material----_____________________Depth of filter material-__-------------------Total length_"_.----------------•-____________"l___, <br /> Seepage .it: Distance to nearest well-_/pAk----1------Distanc om foundation----/A--------- Distance to nearest lot line._____.__ <br /> Number of pits._._.J.____._,____-Lining material" 1 <br /> `1 C __._.Size: Diameter._._ .4_____Depth_..' -�________________ x <br /> Cesspool: Distance from nearest well----------_______Distance from foundation--------------------Lining material-._.-_-------------_____._ <br /> ❑ Size: Diameter---------------------- ---- --}__.Depth------ -----------------------------------------Liqu;d Capacity----------------------------gals. <br /> _(,r'� <br /> Privy: Distance from nearest well------------------ from nearest building_..---------------------------__.------- <br /> , . <br /> ❑ Distance to nearest lot line--------------------- ----- ----- - ---------------------------•---•---------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):---__-/_:___ .._/ .____ __` � � � -------------------------------------------- <br /> ----- L/ <br /> -----------------------------------------------------------•-----_-:----------------------------•--•----------------------•-- ---------------------------------------------------------- <br /> ----------------------------- --------------------- -------------------------------------•-----------------------------------------------------------------------------------------------------I-------------------- <br /> I <br /> ----------- -I hereby certify that l have prepared this;application and-that the work will 6e done in accordance with,San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> 1 ' <br /> (Signed)------ --------------------- ---------------- -------'_------------------------------------- - - (Owner and/or Contractor) <br /> L <br /> Cn ----- ------- --------- -----(Title)--------------------------- --------------- <br /> Y------------------ ---------------- ,I <br /> (Plot 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 ACCFPTED BY-------- ------------------------------------------------------------ DATE------- -------- ----------- ------ ; <br /> REVIEWEDBY--------------------------------------------------------------------- ------------------------------------------------------ DATE----- --------------------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------- ----- ------------- DATE---------------- ------------------.--- y' <br /> " <br /> _ -Alterations and/or recommendations:.___ ------ <br /> ------------- <br /> ......r------� ----------------- -------------------------------------- ---------------------------------------- ------------------- ----•--•----•--------- <br /> -------------------------------------------------------------------- ------ ------------------------------------------------------------------- ---------------------------------:------- -------------------------- <br /> ----------------------------------------------------- ---------------------------------------------------- ------•----- <br /> ----- -- ------------- <br /> FINAL INSPECTION BY: -t Date _ ' S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazollon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.oLi, <br />