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APPLICATION"FOR SANITATION PERMIT- Permit No./.:��.--------- <br /> (Complete in Duplicate) S <br /> h T Date Issues! ._/_,117 __ <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 /> .� ..... <br /> XL"�� <br /> JOB. ADDRESS AND OCA710N----����_� -F- - "IL�t -"-"1----------------•-•---------------------•------•-•-- <br /> ------------------•----­ --------- <br /> Owner's Name---- !_ ---- ----- .-2 •-------------- ---------------------------------- -------:--------- ---------- Phone.---••---------------------•-------- <br /> ----- <br /> i <br /> Address------- �" ._ f ---------------------------------------------------------------- --------------- --------------------------------------------•------------- <br /> ------------ <br /> Contractor's Name------ `# -------------- ------ ------ Phone--------- _-----•---- <br /> Installation will serve- Residence Apartment <br /> _4ouse ❑ Commercial E] Trailer Courfi E] Motel ElOther ❑ r <br /> J ; �'v �0K °i� - � <br /> Number of living units: ______ Number of bedrooms ________ Number of baths ._._____ Lot size __ __________ ____ Q_________-.. � <br /> t <br /> "1%'Water Supply- Public system v Community system ❑ , Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑} Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �a dpan ❑ <br /> Previous Application Made: Yes ❑ No ©1 New Construction: Yes [0 No ❑ FHA/VA: Yes F] No ®' '.. <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitfed if ublic sewer is available within 200 feet.) ' <br /> Septic <br /> /Tank: Distance from nearest well_________' Distance fr fa dation_/0___________ .Mate is __.__._.__ _____-I <br /> r No. of compartments__________ 1________ Size._ ` - .-- Liquid depth__s____________________Capacity.. � � <br /> ' 110�' Distance to nearest lot line._.m_._____.__ <br /> Dispos I Field: Distance from nearest well______________ Distance from foundation___.__ ._ �.__ <br /> Number of lines__________ _ ___ z Length of each.line___--__-_______ Width of french_______-____r ------- <br /> '-Type <br /> -�---�_.%... <br /> '`-Type of filter mater ft_ -_ �/ Depth of filter matenal____.__�-::_____Total length_____________`-�_ <br /> Seepage Pit: Distance to ne est welf--__._.__.__~____---Distance from foundation`_-"--_______.Distance to nearest lot line_________________ <br /> ❑ Number of pits---------------------Lining material-_" -" :----:Size:•Diameter-y________---},R----.Depth_-------- •-----:--------_.- <br /> Cesspool: Distance from nearest well-----------------Distance from-foundation__-----------------Lining'material________.______.__,___--____.____.____- <br /> ❑ Size: Diameter--------------------- -----------------Depth--------------------- -----------------------------Liquid Capacity----------------------- gals. <br /> Privy: Distance from nearest well----___-----------'------------------------------Distance from nearest building----------------------,_-____..____.___._- O <br /> ❑ Distance to nearest!lot line---s:--------------------------------------------- ---------------------- ----------------------------------------• V <br /> Remo•eling ,and/or repairin (describe).--. --- 1----------------------------•---------••----------------------------------------------------•-----._........._--------------- <br /> = .: --- _`d'��.-�€-, 4. --- --------------------------- •------------------------------------------------------------------------•------ <br /> -------------•------------------------------------•-----------------------------------------• ---------------------------------------------------------------- -------------------------------- <br /> ------------------------------------1 ----------------------------..--------------------------------------------------------------------------------------------------------------------------------------------•----------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> l <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> {Signed] �`! > - --------------------------------- = ------------------(Owner and/or Contractor) <br /> / Y, V' <br /> --------------------------------- <br /> By:----------------•-3'--------------------------------------------------------�------------ (Title) <br /> (Plot plan, showing siie of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> t FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- DATEV------------------------------------------------------ <br /> % <br /> } REVIEWED BY------------------- <br /> ---------- --`---------- ------- ------------ ------------=------------------------ - DATE_-- ` <br /> BUILDING PERMIT ISSUED DATE - ------------------------------ <br /> Alterationsand/or recommendations------------------------------------------------ -----------------------------------•-•-----------.------------------------------------------------------------- <br /> ---------------------------- <br /> -------•----------•---------------------------------- ----- ----- ----------------------••-----------------------•----------------------------------------- --- <br /> FINAL INSPECTION- BY:------ <br /> 0: <br /> - : ^ ---- ----- Date------ ... = <br /> SAN JOAQUIN LOCAL HE TH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revises 1.57 F.P.CO. <br />