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FOR OFFICE USE: <br /> 2// d-�------------ --------------------- <br />--------------------------------------------------------- <br /> APPLICATION FSR SANITATION PERMIT Permit No. . .................... i <br />- <br /> ------------------------------------------------------- <br /> (Complete in Duplicate) S— <br /> Date issue <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 Ordinance No. 49 <br /> JOBADDRESS AND LOCATION.......2-7____S f ----•- --------------------------------------- ---------------------------------- <br /> Owner's Name----------- Phone------------------------------------ <br /> Address------------- l ---------------­- <br /> c--.' ``' <br /> Phone..- <br /> Contractor's Name-- - ---------------- <br /> lr - p ----- --------------------------- <br /> Instaliation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑_ <br /> 11 <br /> Number of living units: ___ Number of bedrooms- Number of baths -------- Lot size '-- fJ-- --- -5-- --------- <br /> Water Supply: Public system 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 M Hardpan ❑ <br /> Previous Application,Made: {lf yes,date.-------------------) No 0 New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> {No septic tank or cesspool permitted if public sewer is available within 200 feet.} <br /> 1 <br /> Septic Tank: Distance from nearest well-----_-------Distance from foun ation__Z�___--- <br /> .Materiai�il� weZ¢----------------- ---- <br /> --�--------------Capacity- <br /> (� No. of compartments.. _. <br /> ___ _ ___________Size____'rx_fr��___� ___ Liquid depth -4/- --- <br /> Disposal Field: Distance from nearest ell..."-_ -._Distance from founclat-onZ4-�--__.Distance to nearest lot line_____....S--�� <br /> Number of lines__ ._ _..._/_ Length of each line_ - �-3 --.Width of trench.- ��__.�_________________ J <br /> Type of filter material__.__-Depth of filter material__ -"--------Total length____X� .____________________- <br /> N <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line-----.----------- <br /> ❑ Numberofpits- -------------------Lining material------ ----------------Size: Diameter------------ ---------Depth---------------------------------- <br /> Cesspool: Distance from nearest weil-----------------Distance from foundation--------------------Lining material-_-.--------------------..------__.._. <br /> ❑ Size: Diameter--------------------------------------Depth-------------------------- ------------------------Liquid Capacity---•----------------------gals. V) <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------------.-. <br /> ❑ Distance to nearest lot line------ ------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)--------- ---------------------------------------------------------------- --------------------•--- ------------------------------------------ -- - <br /> -------------------------#---------------------------------------•------------------------------------•------------------------------------------- <br /> ---------------------------------- -- . <br /> ------------------------------------------------------ - <br /> R <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 rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ------------------ -------------- <br /> (Owner and/or Contractor) <br /> BY� - ------------- - - ------ -------- -- {Title} <br /> {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed an reverse side}. <br /> FOR DEPARTMENT USE ONLY <br /> --- DATE---�J--��'"G`�------------------------------ <br /> APPLICATION ACCEPTED BY_-- - F- -- ------------------------- / <br /> REVIEWED BY----- ------------------ - ------- ----------------------------------- -------- DATE <br /> ----------------------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE--- ----------------------------- -------------------------- <br /> Alterations and/or recommendations-------------------- --- --- -------------------------•----------------------••--------------------•-------•------------------------------- <br /> = - -------------------------- ---------- ------------ ---------------------------•----------------------------- ------- <br /> l -------------------------------------------------- ------------------ -------------------------------------- ------------------ - ----- --- <br /> ------------------------------------------------- - <br />' FINAL INSPECTION BY:-.__ .� Date--- -.�9 ---------------------------- <br /> -- <br /> t 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 /> F.P.0 O. <br /> f wl <br />