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FOR OFFICE USE: <br /> --------------------------------------------------------- <br /> --- -----�------- ---------------------------------- APPLICATION FOR SANITATION PERMIT Permit No :�!r/, F .... <br /> ----------------------------------- --------------- --- (Complete in Duplicate) Date Issued �-f-d--_7 <br /> --------------E------------------------------------------ Thiis Permit Expires 1 Year From Date Issued _,� 7 <br /> Application is herebymade to the San Joaquin Local Healfh 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--------- �4 SO <br /> - ~�Owner's Name--------- -- ^ / T AI M4 <br /> _ ________ - VI-� Phone. ------- �•-- <br /> � <br /> Address .Z -------------------------------------------------------------------------------•-------------- <br /> Contractor's Name-------------------------•-----------------•----•------•--------------------------- ----------------------------------------------------- Phone---------------------------------- <br /> Installation will serve: Residence C�( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ <br /> Number of living units: -�":--- Number of bedrooms _ - Number_ of baths`'---/--_ Lot size _a---- /1 .�_.__-__-_--_-__.____--_ <br /> Water Supply: Public system VCommur;ity 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 2--'Hardpan ❑ <br /> Previous Application Made: Ilfyes,dote---------------------} No ❑ New Construction: Yes R"'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 /> Septic Tank: Distance from�riearest we4------ -_-------Distance from foundation_--?D_ --------Material---- -_------------- <br /> No. of compartments--------�___---.....Size--------------------------------Liquid depth-----'1� �---._Capacity---000---/- -- <br /> Disposal Field: Distance from.nearest well. ___` _ --Distance from foundat' Distance to nearest lot line-- <br /> Number <br /> ine-Number of lines----------------2---------------Length of each line Width of trench------- <br /> Type <br /> -..--_ _ .�` <br /> T e of filter material _,.5 r� <br /> yp .�� �z�- epth of filter material length-W--- ._ -- _ -_-�d-.- <br /> ` - J <br /> Seepage Pit: Distance to nearest welL_________ _________Distance fr f ndation___ ©-..__-_.Distance to nearest let line--_Jr-_-_-._ <br /> Number of pits_-..--/-------------Lining material,__ Size: Diameter___-�.k��Depth__.__r�sr F <br /> --- <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----.-----._-_________---_------.--------. <br /> ❑ Distance to nearest lot line--------------------------- ------ ------------ -------------------------- <br /> ,­2 <br /> ------------------------ ✓,� _ f� <br /> ribe :-._�� �?�-- s'�` - -------------------------------------------- <br /> ----------- <br /> ----uy-- T <br /> =/"--------- <br /> Remodeling and/or repairing (desc / �-- <br /> --------------------------------------------------------- -------------------------------------------- -------------------4--- <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 rules and regulations of the San Joaquin Local Health District; <br /> (Signed) -------------------------------------- -------- ---------------- -------------------------------- --------------- ------------ .(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 on reverse side). <br /> FOR DEPARTMENT USE ONLY 7 <br /> APPLICATION ACCEPTED BY---- t ------------------------------ DATE-----' <br /> REVIEWED BY------------------------------ . '------------------------------ DATE_ <br /> BUILDINGPERMITISSUED------------------------------------------------------------------------------------------------------ DATE---------------------- <br /> Alterations and/or recommendations------------------------------- --------------z <br /> ------------------------------------------------------ ------ r <br /> ---------- ------------ - r— I] �(�� <br /> -------- --------- ---------- -'------------------- <br /> ------------------------- ----------------------------- - -- ------ - / -------------------------------------------------------------------------------- ---------------- <br /> r <br /> FINAL INSPECTION BY .............. - -- ----------------------------------- Date--.----- - ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.tfazolton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.P.a q. <br />