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FOR <br /> OFFICE-�� <br /> _____ __________ __________________________________ APPLICATION FOR SANITATION PERMIT Permit No. ... <br />--------------------------------------------------------- (Complete in Duplicate) <br />...................................... ..............._. This Permit Ex ires i 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 <br /> /No. <br /> '549. <br /> JOB ADDRESS AN LOCATION___-... ._...�✓...IO*9. ,� �/ �����..---A _ <br /> Owner's Name 0,0 <br /> -•--- C7`.[ Z7G-4- ----- Phone. 7.� � <br /> ---------------- <br /> Address-------------------_--.......... . tr 7 ---------- ------- . ,f.....-----------............. <br /> OL <br /> Contractor's Name- fi,['-- ,(Ja fXl �j --•---------------------------------------- Phone_,71� �.� <br /> Installation will serve: Residence ®' Apartment House ❑ C mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> '._ Number of .aths _.1.- Lot size .7-- �.d � <br /> - --- . <br /> Number of living units. J... Number of bedrooms __�Water Supply: Public system ❑ Community system ElPrivate Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑�'XNew <br /> Loam ❑ Clay Loam ❑ Clay ❑ dobe Hardpan ❑ <br /> Previous Application Made: {If yes,date...____..-_.___,) NoConstruction: Yes ❑ No FMA/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 /> is T k: Distance from nearest well.................Distance from foundation--------------------Material-_.....-_.-.•..-...._--------_._----------------- <br /> No. of compartments-----------------------•-Size--------------------------------Liquid depth--------------------------Capacity................... <br /> sal i Distance from nearest wel!�b?.-�.-._Distance from foundation.,/Q__�.......Distance to nearest lot li e..+{ <br /> Len th of each line._.- .Width of trench.. _.._...� <br /> Number of lines.-..__/_._ g ..r.__-.-. s. <br /> r �.. <br /> ,� Q Type of filter material <br /> 11 <br /> -Depth of filter materia----._.-.,e !.Total length.........................r----.f�_._... <br /> Seepage Pit: Distance to nearest well................. ....Distance from foundation....................Distance to nearest lot line_-..-.-..-__----- <br /> ❑ Number of pits----------------------Lining material---.-.-.-------.._._.-Size: Diameter------------.--.-------Depth................................. <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 /> Remodeling and/or repairing (describe):---------------- ------------------------------------------------ <br /> ------•------------------•-------------------------•-------------------- ------ ----.------ - <br /> ------•---•-----•------------•--------- -------•----•--------------------------•--• -----••--.....---- <br /> ----------------r------------------------­-------------------------------------------------------------- <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, Stat ws, and rul and regulations of the San Joaquin Local Health District. <br /> (Signed) ! •- •�a - � Contractors <br /> B • <br /> + ----------(Title)---------------------------------------- - <br /> (Plot plan, showing size of lot, location of system in relationjwe_�Ifs,__buildings tc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- -------------------------•-------•---•--------------------------. DATE......... .- •------------------- <br /> REVIEWEDBY----------------------------------- - - -------------------------------------•--------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED--------------------------------------------•-----------•-••------------------------------------------ DATE.------------------------------------------------------------ <br /> Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------- •---------------------------- ...._.----.--- <br /> -------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- ................................. <br /> FINAL INSPECTION BY:. f.--•---------------- Date---�.E�.�.�._l__.�.�-.:� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Wert 9th street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> CS 0 REVISED 8-99 21A 8-61 ATLAS <br />