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FO OFFICE USE: 7 9�. ?9-3 <br /> APPLICATION FOR `SANI 'ATION PERMIT Permit No. C_Le.z...�.� <br /> ---------------------------- ---------------------------- (Complete in Duplicate) Date Issued =.1�_- � <br /> _____________________________________________________ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made 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 OCA�TIIIOWN-.---- -------------1-�� �­ ­r--�1.0-r---------------------------------------------------------------------------------- <br /> Owner's Name__ •' 1f4.W�- - ------------ Phone-------------------- <br /> s €� ` <br /> Address------------•i------- a� � ---------------------------------------------------------------------- <br /> Contractor's NameP' 1C ---------------------------------------- <br /> •-----------•-------------------- Phone----------------------------------- <br /> Installation will serve: Residence V Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ <br /> } <br /> Number of living units: _/._ Number"of.bedrooms-,..5_--. Number of baths _eo_-_ Lot size w _ _. (1-------------------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tablef . <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®/11ardpan ❑ <br /> Previous Application Made: {1f yes,date____________________) No ®`New Construction: Yes ❑ No U20'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: e- Distance from nearest well-,_-------------Distance from foundation------.-.---.------.Material-------.----.-.--------_____-_____-._-_-___-___-. <br /> P .q P. Capacity----------------------- <br /> ��]��� No. of compartments Liquid de th___..-______...-_____-- <br /> Dis osal Field: Distance from nearest well - -Distance from foundation__ ___ I <br /> p - _ ��_.___`_.Distance to nearest �t line_ ____ -_-_ � <br /> Number of lines_._._---_- Length of each line, ___- . _-A_-__..Width of trench_i ----------------------------- <br /> Type of filter materia!' � ' Depth of filter material-- -___--_.Total length_A�7C -------------------------- <br /> e4ae. t- Distance to nearest well-._---`-r'-------Distance fpfoundation,,e*'bO�-----__.Distance to nearest of line_��___-_ <br /> Number of pits. /------------- material-, 4e__Size: Diameter_���_.___--Depth -0�/ ie.__ <br /> 411Distance from nearest well---------------Distance from foundation....................Lining material------------------------------------- <br /> VV <br /> ❑ Size: Diameter------------------------------- ----- Depth----------------------------- ------- -- ----------Liquid Capacity- ------------------------gals. <br /> Privy. Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line--------- ------ ---- - <br /> ---------------------------------------- - ------------• ------------------------------- <br /> Remodeling and/or repairing (describe ---- ---- -- -- --- =----- ------------------------------------------------------------------ <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 law nd ules and la+ion of +he San Joaquin Local Health Dis+ric+. <br /> r <br /> �-�"" Contractor <br /> (Signed)-------------- - --- ---------------------------------------�c�!�d,on <br /> -- 1 <br /> ------- <br /> By------------------------------------------------------------------- ----------(Title) <br /> --- ------ <br /> (Plot plan, showing size of lot, location of syste relation# to wells, buildings, etc., can be pareverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -------------------------------------------------------------- DATE------------- G.. C'----------------------- <br /> REVIEWEDBY------------------------------------------------------------------------------ ---------------------------------------------- DATE--------------------------- <br /> -------------- <br /> BUILDING PERMIT ISSUED-------------------------------- /n -- DATE---------------------------------- ------------- <br /> - <br /> Alterations and/or recommendations:____-_----- ' __.__ <br /> ---------------------- <br /> ---------- - ----- ------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----•--- <br /> ----------------------------------------------------------------- ------- ------I-------I--------- ------------------------------------------------------------------------------ - - ------------------------------ <br /> FINAL INSPECTION BY:------------ --------------------------------- ------------- Date--------------- .-f��------------------- <br /> --------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxolton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca, California Tracy,California <br /> F.P.CO. <br />