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t FOROFF iE U E: <br /> APPLICATION FOR SANITATION PERMIT Permit No. __ " <br /> --------------------------------------------------------- (Complete in Duplicate) /3 <br /> Date Issued <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date 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 Ordi ante No. 54?,. <br /> JOB ADDRESS AND L�TJO 1 (/ = -------------------------------------------------- <br /> --------.-_.•---------------------------•-- <br /> ----- <br /> Owner's Name----------- ---------- -------- Phone...-.... <br /> Address--------- -------------- ------------------------------------------------•..................------- <br /> Contractor's Name------------- 1 Phone.....................---------._.. <br /> Installation will serve: Residence U5o'Apartmont House El Commercial E] Trailer Court ❑ Motel ❑ Other El <br /> de <br /> Number of living uriifs: ../-. Number of bedrooms _tom►. Number of baths _/---- Lot size 44k-1— Q ----------------------- <br /> Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table _4vft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No v(4-.rNew Construction: Yes ❑ No Edo-,�FHANA: Yes ❑ No [C r- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank ori cesspool permitted if public sewer is available within 200 feet.) ( <br /> "I ♦ I <br /> Septic Tank: Distance from nearest well---- -------Distance f om <br /> ..._ found&f.ion---- <br /> 1,69Mateal--- �C-}'` <br /> No. of com artmenfs-.___ _____-_____.-Size _ <br /> _ 46Liquid de th---- --- -' Capacity--, _--Q�---_ <br /> i <br /> Disposal Field: Distance from nearest well------.. ----- Distance from fopndafi n.._/ ---------Distance to nearest lo, M--_---- <br /> Number of lines-------- f-.._ _----- Length of each line-- Width of trench__ ------________________________ <br /> Type of filter material- -Depth of,filter material_-_-., --------.Total length-.... .................�_.. `^ <br /> Seepage Pit: Distance to nearest won----_.'�_^--.---Distance from foundation___A*F_Distance to nearest lot line__._-..- oU <br /> r <br /> [7� Number of pits--------/r-__-------Lining material.._��1�.-Size: Diameter_ � <br /> - .'��--___Depth-.-�--f--------------- W <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.-____---.--__-_____-..._----_----. <br /> ❑ Size: Diameter--------------------------------------Depth------------- •----------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------T__---_----Distance from nearest building-------------------------_-_----_----.-.-. <br /> ❑ Distance to nearest lot line---------------- ------------ ---------------------------------------------I--------­______.---------------------------------------------------- <br /> . e <br /> Remodeling and/or repairing (describe):------------- XPi + -..--- E,r' ------ f •-..---•--.. <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, State laws, and r es and regulations of the San Joaquin Local Health District. <br /> (Signed)------------------- -------------------------- - --(CWwaaiixwJ�or Contractor) <br /> By:------------------------------------------------------------------- ---......(Title)..- �,�l� - <br /> ------------- <br /> (Plot plan, showing size of lot, location of system i r tion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ,`-- DATE ------------------ <br /> REVIEWED, BY------------------------------- - ------- -------------------------------------------------------------------------------- DATE-------------------•----...._ <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------ <br /> Alterations and/or recommendations----------------------------------------------------------------------------------------------------•--•------------------------------- <br /> ------------------------ <br /> -------------------------------------------------------•--------I ---- ----------------------------------------------------------------------------------------------------•--. ----- -------------------- <br /> FINAL INSPECTION BY--------/.. -- -- --------- ------------•---------------- bate-------------------- - --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca;California t Tracy,California <br /> E8-9 REWSED 8-59 F.FZO.3M 6.60 <br />