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FOR OFFICE-USE: <br /> ------------------ •----------- <br /> '- APPLICATIdWFOR SANITATION PERMIT Perini+ No, <br /> }(Cn Dup. <br /> om lets rae Date issued <br /> -------- ------- ----- - This Permit Expires 1 Year Date Issued <br /> -�' - - ------- -- <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 /> JOB ADDRESS AND LOCATION.-..---.- � IT---------- <br /> . -- <br /> �� L-- <br /> j-Cf fOwner's Name------------------------ ---- -- ---------- ----- ------------------ --- - ---- -- <br /> Phone <br /> Address------------------------ `�q2 . -•---------------• S- _ '----- -___- -••------------- <br /> Contractor's Name-----------------------------------I ------ Phone----------- -•------ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial,[]--Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __-_ Number of bed.rooms -------- Nurnber,of baths _______`Lot size ____________________________________________________________ i <br /> Water Supply: Public system ❑ Community syTe-IF,❑- 'Private'C]—Depfrto'Water Table ________ ft. ' <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> % a .a. <br /> Previous Application Made. (If yes,date_..�l�I � No ❑ � New,Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 932-9 _ <br /> (No septic tank or cesspool permitted if public sewer'is available within 200 feet.) <br /> I I <br /> is Tank: Distance from nearest well____,_-_I,-_ -Distance from foundation___________________ Material-------------------------------.___-__-----____. <br /> No. of compartments______ -_--- -4--------Size----------------_--;---"'------Liquid depth------------------.------.Capacity-- <br /> Disposal Field: Distance from nearest well _ Estance from foundation_____©_.___._Distance to nearest lot line____147- <br /> "2 <br /> _�__ <br /> Number of lines___-__ -0 �__.__aLength.of.each.line_.•_ _Q_i- Width of trench------- ' <br /> ------- <br /> Type of filter material___ Z _____Depth of filter material__., _ _._-_TataI length___________________fd <br /> .� .�,. � . -I ._ -- <br /> Seepage Pit: Distance to nearest well.----___--------------Distance from foundation--------_----------.Distance to nearest lot line----___-__--____ <br /> Number of pits----------------------Lining material----------.------------Size: Diameter-----------------------Depth--------------------------------- \ "# <br /> esspool: Distance from nearest well__________-____-Distance from foundation--------------------Lining materi -- ' <br /> ❑ Size: Diameter-------------------------------------Depth------------------ ---------------------------------Liquid Capacity - -------------------------gals. <br /> Privy: Distance from nearest well------------------ -------------------------.____Da stance from nearest building__.______.______-____________-___---.._: <br /> ❑ Distance to nearest lot line_--------------------- - ------- --------------------- -------------- -------------------------------------------------------------------- -� <br /> Rem doe rig and or repairingdescrib - ----------------------------------------------------------------------------- <br /> ------------------------------------------------------ ---------------------------------------------------------------------- <br /> - ----------------------------------- -----•----------------- ----------•------------------------- --------------------------------------•-------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, to laws, and rules and re cations V�v <br /> oaquin Local Health District. <br /> (Signed)___ P (Owner and/or Contractor) <br /> -- --- ----------- <br /> BYP ------------------------- (Title) <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 ACCEPTED BY---------------------------- -- DATE- - -- _ -- _ <br /> REVIEWED BY �`---------- ------ --------------------------------------- <br /> --------------------------------- <br /> - ------ i ----- DATE <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------- DATE---------------------------------------------------- <br /> Alterations and/or recommendations-------- --T-------- ----------------------------------- ------ ------------------------------------------ -------- <br /> -------------•---------------------------------------------- -------------------- ----------------------------------------------------•---•-------------------------------------------------------------- ---- y <br /> --------- ---------- ---------- -- - ---------------------- --------------•----------------------•---------------------------------- <br /> ------------------------- ---------- -------------------------------------------------------------- ---- ----------------------------- --------- ---------------------------- ------ -------------- ------ --------- <br /> ---------------------------- ------- ------------------------------ - ---------------•------------- <br /> ------- ------------- •---- <br /> /f- /l9 <br /> FINAL INSPECTION BY:. -------------------------------- Date - / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />