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F R OFFICE US <br /> ---------------- <br /> 11 <br /> APPLICATION FOR SANIS`ATION PERMIT Permit No. <br /> -------------------- --------- ----- -- _ <br /> (Complete-in Duplicate) Date Issued <br />---------------------... .....--------...-__-------------- This Permit Expires 1 Year From Data Issued <br /> Application is hereby made to the SanyJoaquin 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 /> JOB ADDRESS AND LOCATIO 02� '--.. ...• ---------------------------------------------------------------------------- <br /> _�Z ----•---------------------------- ------------------- ------------- Phone__h��. <br /> Owner's Name, ® _- ::-________ _______��y � <br /> Address . �� ---p---------------- -- --------- --• --------------------------------------------------..--------------•----- ••------ -------•- <br /> Contractor's Name <br /> -=� Phone <br /> Installation will serve: Residence 0 -Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __�._._ Number of bedrooms _- Number of baths---- Lot size -_-_ ________ W, <br /> Water Supply: Public system Community system ❑ Private [7Depth to Water Table-A0.ft <br /> Character of soil to a depth of 3 feet• Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ® Clay ❑ Adobe❑ Hardpan ❑� <br /> Previous Application Made: (If yes,date--__-------------- ) No ® New Construction: Yes ❑ No ® FHA/VA: Yes ❑ No [R- <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 /> ❑ No. of compartments------- ------------------Size--- ----- ---=------ -----------Liquid depth--------- ---- - --------Capacity--------•---------- <br /> . ------ <br /> Number <br /> I <br /> Disposal Field: Distance from nearest well...---__.....Distance from foundation----fly-------_.Distance to nearest lot line--_,S.- --. ^ <br /> Type er filter mat / - -----------------Length of each line-..._�s --------- ---.Width of trench....rr2-y-�� ...._._..--.... <br /> ® Number of lines.___ <br /> erial__1�s?.�11r------Depth of filter material----/8`! .-....Total length....��5_`__________________________ <br /> Seepage Pit: Distance to nearest well-_-_-~--------------Distance from foundation_-_14.-_--_-__.Distance to nearest lot line__- �_____ t <br /> ® Number of pits._. _1----------...Lining material--_ Q_±*LI'..-_ Size: Diameter- 3-3"'_-_..._--Deptfl___.Ak5-------------------- <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.,,, line -------- ------------------------------- --------------------------------------------- --- -----------------------•--------------------- <br /> Remodelingand/or repairing �descrilbe):-- ---- -------------------------- ----------- ------ ---------------------------------------------- ----------------------------•------------------ <br /> -----•------------•-._------------------------------------- )-------------- ------------------------------------ -----•--•-••------------------------- -- - ---- ------------------------------------------------------ - <br /> --------------------------------------------------------------�-----------------------------------------------------•-••-•------------------------------------------ ------- ---------------------------------------------­ <br /> ------ <br /> I , <br /> --- - -- --------------------------- --------------------------- ----------------------------------------------------•-•-.._...•----------------------------------------------------------------- ---------------------------- <br /> . <br /> ----------------- - Y <br /> • I'hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-_-- ` --- ! ------(Owner and/or Contractor <br /> 1 <br /> BY=--- -- ._ _Farms -------- ---- -----------___---------------------(Title) - -------- ------ - --- ..---------- ------- I <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> ` F <br /> ( FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- -- - 4--- -- ------------------------- ----------------------- -------------- DATE_---` - �---------------- --- i <br /> a <br /> REVIEWEDBY-------------------------------------- ----- ------------------------------------------- DATE------ ------- ----- <br /> BUILDINGPERMIT ISSUED-------- --------f---------------- -------------------------------------------------------------°--.- DATE- - <br /> Alterations and/or recommendations:.'.... ------ ------7�-........&'�..--- -------— <br /> -------------- <br /> --- -------- ----------- --------------- ----- <br /> 1 c. ---�------ . -- ---- `�� ----- -�` ' G -�- ---- <br /> -------- <br /> - y - ------------------------ <br /> FINAL INSPECTION BY:.. ----- ----------- De+e _.- �� ----------------------------------------- <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1.67 Vanguard Press <br />