|
AOR OFFICE USE;
<br /> APPLICATION FOR SANITATION PERMIT Permit No. .1211/16;�.4?
<br /> (Complete In Duplicate)
<br /> ? -•• This Pormit Expires t Year kem Date Issued Dnte Issued
<br /> �PPlication is hereby made to the San Joaquin Local Health District for a p,*rmit to construct and install the work herein described.
<br /> Tl,is applIcet" jI a in c plience oh my Ordinance No. 549,
<br /> JOB AWf� SS D Laf�ff�Ivlt�,----- J, �-
<br /> Owner s Neme..�c.............»>:..,G ......._ ..... .......... �. ... _..............
<br /> Addresa,......�...»...•. ................'r/� '...... .' _l Phone.... ....... ................»...
<br /> Contractors (JarneL.!1.r�r�st,L.v••�` ,,F:�T�../-*o* r2 -";l,1'..�...f,... «.......•. ... . .ono.... ..............».....».».» y{�
<br /> . SMS........................ ... Pf,Ontl... .... .............».......... i
<br /> Installation wig serves Residence A artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other O f
<br /> Number of living units: ..ti.. . Number of bedrooms..;... Number of t.,oths Lot sizu
<br /> Water Supply: Public system ❑ Community system ❑ Private Q Depth to Water Table ft.
<br /> Chareder,of SGJ to a depth of 1 feet: Sand❑ Gravel ❑ Sandy Loom 0 Clay Loam 0 Clay 0 Adobe❑ Hardpan❑
<br /> Proviow Application Modes (if yes,dote .... I No ❑ New Construction: Yes ❑ No I'HA/VA, Yes [i No❑
<br /> Ti pr GF 1:4STALLATION AND SPECIHCATIONS: O�
<br /> (No septic tank or cesspool permitted If public sewer Is available within 200 feet.)
<br /> Septic Tank: Distance from nearest
<br /> ❑ woll.r .R.........Distanco
<br /> ....f.ro.m. foundation...j•No. of compartments r.«.............. tie... : . ......Liquid
<br /> Mu car iol
<br /> depth... : Capacity... �
<br /> Disposal Fieid: Distance from nearest W91113a4,........Distance from foundation.;.J%............Distuncu to nearost lot line...T...........
<br /> D Number of Itnes.,..a...........................Length of each line......:.5..... ....
<br /> Type of filter materiel..),,.R, .Width of Crunch ......................
<br /> .............Depth of filter material...1.'�:�.., Total lungth •
<br /> Seepage Pit: Distance to nearest well.,,....»... ,Distance from foundation. •. • . ...
<br /> ❑ Number of pits.................... � .»•... ... r •••••"•••••.••..Ojyter�cv to noaru:t lot lino.. .............
<br /> .#g material. ...... ...........';to: Dlemefor., ... Dupth
<br /> Cesspool: D:sfence from nearest well.............I Distance from
<br /> .' fNNIA1 .....
<br /> lntnt� nelurtel13 Sao: D:amatir......... . .. .................................
<br /> + ep ............................. .• ......... . . LOid Cnpecity ...... gels
<br /> . 4.
<br /> 3
<br /> Privy. Dislicrice from nearest well........... •
<br /> • •..••••• ,1Lstance from noerust I,i;Id;ng
<br /> ❑
<br /> Distance to nearest lot lin...... t """'..""""""
<br /> Remodeling end/or repairing (describe):...... ... «•........�.... ... .......r,....�............. f
<br /> .... ......•...............................................................»....»............»...«..�.... .a. •.w...f•�».•..»............... ...... .....�..........••..............
<br /> .....
<br /> I . .
<br /> ....
<br /> . ....................... .......................................... .....»...«......... ... �........ _ .... ............... . ................... ..
<br /> .......
<br /> I hereb certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County
<br /> ..............
<br /> ordinances, tate laws, and rubs and regulations of the San Joaquin Local Health District.
<br /> (Signed)............. ...................
<br /> Y•.
<br /> �J •••••••.••• .. (Ownor and/or Contractor)
<br /> By:....�.1 J_ 7.4a...- ....�.:�.... -ria! .?fi................ (Title)
<br /> ..... ................................ ..
<br /> (Flot plan, .bowing rise of lot, location of sys rm in relefi:i walk, buildings,etc., can be placed on reverse side).
<br /> FOR DEPARTMENT USE ONLY
<br /> APPLICATION ACCEPTED BY >r:....1_..: _.,...+;,�...:`........... .. -
<br /> REVIEW[D BY.... .............................................. DATE.... .................. ...... ..........................
<br /> ......................... .....I...............I......... DATE.
<br /> BUILDING PERMIT ISSUED.. ............................................ . . ..,............ ............................ '
<br /> Alterations and/or recommendations: DATE.. . . ....... ......... ... . .................»....... 1.
<br /> ons: .... .....................................................................................
<br /> ............... _ _
<br /> ... ..... . . ...• .... .. ............ ..................... .................................................................. ............. .............
<br /> I1AL INSPECTION BY:./�i,: ar�.�c�r�rT'................. Date. l
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT.
<br /> 1601 E.Hosel#on..v@. 300 West Oak Srroot 174 Sycamore fire@#
<br /> 105 West 91h Street
<br /> Stockton,California Lodi,California Manteca,California Trucy,Cohlmnia
<br /> FCU
<br /> ,•r,
<br />
|