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FO OFFICE USE: <br /> .......... <br /> ----- . : <br /> ______ _________ _ ------ -- -------- APPLICATION FOR SANITATION PERMIT Permit No. ..l._. .. ,� <br /> --------------------------------------------------------- (Complete in Duplicate) <br /> This Permit Ex fres 1 Year From Date Issued 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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION------/Y�-- --------- -------- ------ -----------------------------------------•------- <br /> --- - -- - <br /> Owner's Name------------ ,, ;R _ ___ ------ ___._. Phone----------- <br /> Address------------------- -----------------•-----------------------•----------------------------------•-- <br /> Contractor's Name•---------- ------ - ---._. Phone--=• - <br /> Installation will serve: Residence Q Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __j__ Number of bedrooms _____ Number of baths _/.._. Lot size --------7_s. A'_7,:57......................... <br /> Water Supply: Public system fQ Community system ❑ Private ❑ Depth to Water Tabled ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, Hardpan ❑ <br /> Previous Application Made: (If yes,date-----------_--------) No ® New Construction: Yes 20 No ❑ FHA/VA: Yes ❑ NON <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well__�49_ ---Distance from foundation____J__Q_ ----Material__ <br /> No. of compartments--------A------------Size--- ---Liquid depth_-----�_IA_Z----Capacity------e- -_Q--- <br /> Disposal Field: Distance from nearest well---6 61_.__Distance from foundation--- .___.Distance to nearest lot lin„_- <br /> Number of lines_________ _ __________________Length of each line-----------<F_0-p___�!Width of trench-----c;Z Y__ _____.______-_ \ <br /> Type of filter material s-d�pth of filter material--------/f?__ .._-.Total length---____974V_____________________ \� <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line................. <br /> ❑l Number of pits----------------------Lining material-------------..........Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from,nearest well-----------------Distance from foundation-------------------.Lining material.------------------------------------- <br /> 0 Size: Diameter_ = ` =- Depth------------rf----•------•------------------------Liquid Capacity---------------------------- <br /> Privy: Distance from nearest well --------------------_-____--_---_______________Distance-from nearest building-_--_.__________-_____________..___.___._. <br /> ❑ Distance to nearest lot line =' '------------------------------ -----------------------•-••------------------------------------------------------------ <br /> Remod i g nd/or repaitiing (describe): _ -,� - _- --------- - -- - -- 2 _--- ----------- <br /> ------------------. <br /> � � t --------- -- --- ----*1 ----------------------- •------------------------ <br /> ------------------------------------------ -----------------------------­- •--- ----- <br /> - - -- -------- <br /> ,� ... e <br /> -------------------------------------------- -: _ — -,a <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, State taws, 'and rules and regulations of the San Joaquin Local Health District: <br /> x <br /> [Signed) _ Q(. r ,�_'_.�r :�4f_ _-_-_______ ___________________(Owner and/or Contractor) <br /> Br• ':- (Title)------------------------------------------- ------ <br /> (Plot plan, showing size 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___ _ ___�_..� ---_-i__ ,!lf� `-____ _-_ DATE----- k 4e�_. ___ <br /> �- -------- <br /> REVIEWEDBY-------------------------------------------------------------------------------------•----------------•----------------------- DATE---------------------------- - <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DA•TE---------------•------------------- <br /> Alterations and/or recommendations------------------------------------------------- .............---------..-------------------------------.------------- ------------------•-------------------- <br /> ---•-----•=-------•---------•---------------------------------------------------------------------------------------•-•--------•----------------------•-----------•---------------••----------------------------•------------ <br /> ---------- -----------------------------------------------------------------------------------------------------------•-------------------------••.---------------.-------------------------------•-•-•----------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I <br /> 4 <br /> FINAL INSPECTION. BY:_. Date-; Z C� �J <br /> tN <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E8-9 REVISED 6.59 F.F.DD.ZM 6.60 <br />