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FOR OFFICE'USE: y <br /> 3- a = <br /> ' APPLICATION FOR SANITATIOnERMIT Permit No. . <br /> ---------------------------------------- ------ --------- _ <br /> -..____.. - (Complete in Duplicate) �� <br /> }_ Date Issued _s - /?------- <br /> - ---Q\._-___---- --- ------------ This Permit Expires I Year From Date Issued a <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. ",J l fp 2-[std-19 OA /- )ew <br /> n � ® _- T may_ <br /> JOB ADDRESS AND LOCATION�----- - - --- .------f _DX ------------------------------ �� I <br /> Owner's Name `'v----- ---------------------------------------- <br /> Address <br /> 1 f-C� ��rJ Zjw-� -----------------­---- <br /> Contractor's <br /> Address----------- - ,�� -------------------------------------------------------------------•---------------------. <br /> Contractor's Name--- ----- ------- --------------------- ------------------------------------------- •-----------------•- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Tr <br /> Number of living units: -------- Number of bedrooms -------- Number of baths ; <br /> a�mss I <br /> i <br /> Water Supply: Public system ❑ Community system ❑ Privateg Depth tc <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ] Hardpan ❑ <br /> Previous Application Made: (If yes,date.-..--_..--_--- -) Noo10 New Construction: Yes 4 No ❑ FHA/VA: Yes ❑ No ❑ <br /> �1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I <br /> Septic Tank: Distance from nearest well___-�....Distance from foundation-.�Q--------- <br /> --Material -------------------- ------- <br /> No. of compartments-----.a-.-..- i-.--Size------ z-'r --_Liquid depth-...�/ L_--'.---.---capacity.l ! <br /> Field: Distance from nearest well..,5— -- Distance from foundation..lQ.............Distance to nearest lot line--------------- <br /> Disposal ` <br /> I <br /> Number of lines------_--.-. ------------------Length of each line-------I-An_----------Width of trench----' _---.------------- <br /> Type of filter material.------------°.."`---:Depth of filter material-----------------------Total length----.-...�.�.,'�`��/-�. ; <br /> Seepage Pit: Distance to nearest w&I----------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> ElNumber of pits.--.------ - --------Lining material--------.-:-------------Size: Diameter-------------------.---Depth------.---------- <br /> Cesspool: Distance from nearest well---------------Distance from'foundation--------------------Lining material---_------.--------------.....__--._.. <br /> El <br /> Size: Diameter 3 ----------Dept h----- '---- ..Liquid Capacity _ .-.._ <br /> els. . <br /> Privy: Distance from nearest welt----- _----------.r--_-----_---. '.---_1---Distance from nearest building---------- <br /> ❑ Distance to nearest lot line'`--------------- #--------- _ -- --•------------------------------------------------------- ---------------------------------- I <br /> Remodeling and/or-'repairing {describe):--- ----- ----- ---- ( = ` �- ! <br /> � <br /> -----------------------I—------- - ------------------- ------------------ - -------------------------------------------------------------------------- -- --------------------------------------------------------------- <br /> � -_ -------------------------------------------------- ----------- <br /> 00 ---------------------------------------------------=------------- <br /> --------------------------------I-------------------------------------------- <br /> I hereby cer+ifj that I have 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 /> (Signed------- - - - ------ -Z--- --- ------ -- ---------------- ------------------------------------------------ ---------------------(Owner and/or Contractor) <br /> Sy:---•--------------------------------- --1 ---------------- --------(Title)------------ ------ --------------- ---------- - -------------- <br /> (Plot plan, showing size of lot, to ation of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY-- -- DATE a_"/Z.." 3 <br /> REVIEWEDBY-------------------------------------------------- ------------------------------------------------------------------------. DATE----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------- -------------------------------------- ------------------------ DATE--- ------- ------------------------------------------------- <br /> Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------_-•-------------------------------- <br /> ----------------------------------------------------------------------------------------- - --------------------------------------------------------------- ------ -------------------------------------------------- <br /> ----------- --------------------------------- ------- -------- -- ........ ------------------------------------- --- <br /> 3 -3 - (06 <br /> FINAL INSPECTION BY---------- ------------ - �a:----------------- Date- --------------------------- ------- ------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxellon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.C❑. <br />