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FOR OFFICE USE: - - <br /> -------- <br /> ---------------------------------- _ ---- APPLICATION FOR SANITATION PERMIT Permit No. .__./�G057 <br /> --------- --------------------------------------- ------- (Complete in Duplicate) <br /> ----------- -------------- This.-Permit Expires 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 /> A 11 <br /> JOB ADDRESS AND LOCATION. , --- ,,4 <br /> ----------•------------ <br /> Owner's Name_-.__E•x-_______•-- J TII <br /> - ----- Phone 4o__ <br /> Address_. <br /> �- <br /> Contractor's Name----- -- - --•- ------------•------ Phone----------------------------------- <br /> Installation <br /> ------ •---•------ --Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: -------- Number of bedrooms Number of bat s --- Lot size ________________________ <br /> Water Supply: Public system ❑ Community system [] Private 14 Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Z Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date__;_______________) No K 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 /> Septic Tank: Distance from nearest well____ ---Distance from foundation......«.--------Material--- <br /> ----------------------- ----------- <br /> No. cf compartments-------- ....... Size------ --X�� _ --Liquid depth---- ----- ---------- ----Capacity-----9�20,7-c4­1 <br /> Disposal Field: Distance from nearest well___ d_r._Mstanceffrom foundation----Ic 5{.___.Distance to nearest lot ling�___� <br /> Number of lines----------j--- ---------Length of each line---------Fe----------------Width of trench______X! ..-- <br /> ---------------- <br /> Type of filter material___- Depth of filter material----------------------Total length_____________________________----___-___ ---Seepage Pit: Distance to nearest well---------------_------Distance from foundation------------------- Distance to nearest lot line----------------- �* <br /> ❑ Number ofits-------------- <br /> P --- ---Lining material------ -- ------------Size: Diameter----------- ----Depth-------- ------------------ <br /> Cesspool: Distance from nearest well--------------___Distance from foundation---------------- <br /> El <br /> materia!-------------------------------------- <br /> ---------- <br /> __.. __-_______. .t <br /> ❑ Size: Diameter ----------------De th--------- -------------------------- _Liquid Capacity als. <br /> Privy: Distance from nearest well---------------_______________________________..Distance from nearest building__-___._______.____.____------_---_--__.. •.� <br /> ❑ Distance to nearest lot line------------------ - - ---------- <br /> Remodelingand/or repairing (describe):------- ------------------------- ------------------------------------------------------------- -------------------- ----------------------------------------------------- <br /> i <br /> .. 1 <br /> ------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ', 1 <br /> ------------------------------------------- ------ --------------------------------------•---------------------------------------------------------------------------------------------------------------- l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordinances, Sta =laws ndr es/rd e 'ulations of the San Joaquin Local Health District. <br /> (Signed --- ---- --------- <br /> --------------------- --(Owner and/or Contractor) i <br /> BY-----------l---------------------------- 7nof <br /> ------------------------- ----(Title)--------------- - I <br /> (Plot plan, showing size of lot, Iocastem in relationto wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ------------------- ------ --------------------------------- DATE- <br /> REVIEWEDBY------------------------------------ -------------- --------------------------- ------ --------------------------------------- DATE <br /> BUILDINGPERMIT ISSUED----------------- -------------------- ---------------------- ----------------------------------- DATE--- ------------------------- <br /> Alterationsand/or recommendations------------------ ------------ --------------------------•----------------------------------------------------------------------------------------------------- <br /> ------------------ ---1------------------------ ---------------- --------------- ------------------------------------------------------- --------------------- -•------------------------------------ <br /> -------------------------------- ----------------------------------------------- ---------------------------- ----- ---------- ------------------•---------------------- ------------------------------ --- ---------- <br /> FINAL INSPECTION BY:.. ---.__ Dste-__` ----1 -` - ----------------------- <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hatellon Ave. 300 West Oak street 124 Sycamore Street 205 West 91h Street <br /> Stocktonr California Lodi,California Manteca,California Tracy,California <br /> F.P.Cp. +�'-� <br />