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APPLICATION FOR SANITATION PERMIT Permit No. .......c... .. <br /> --- --- ------------------------------------- � r <br /> (Complete In Duplicate) <br /> Date Issued <br /> -------------------------------------- This Permit Expires 1 Year From 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 OrdinclQce No. 549. <br /> FJOB ADDRESS AND LOCATION.---------�-Q$ ------------ Q pew`C7` --------------------------------------------------- <br /> Name----------------------- ---- -2lLtilc]�R ...----- Q1l-x- .R- ------- ---- ------ -------------- Phone- -7-7-------�?3 <br /> Address------------ --•----------------•---•--------- -- --�-77---------------C"---- --C-----A- - <br /> Contractor's Name i21 �= ..------- - ..�----------------------------- ------- ---- Phone <br /> will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---I--- Number of bedrooms Number of baths __ Lbt size ---------- _ __ _S-0-_-..-- <br /> Water Supply: Public system ElCommunity system ElPrivate I'dDepth to Water Table #0 ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam] Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: {1f yes,date--------------------.1 Noim- New Construction: Yes ❑ No)9— FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is availa6le within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation------------------- Material--...----.--_-----.-------------__-.----_----_-_. <br /> ❑ No. of compartments------ -------------------Size-------------------------- .....Liquid depth.------------------------.Capacity...-- ------------ <br /> Dispos I Field: Distance from nearest well---A-�Sr--_Distance from foundation_ _-- �--�_. r <br /> ��___ Dis#ante #o nearest lot linje__��---.._.. <br /> Number of lines------------- ------ ---Length of each line----------.__ -__�--------Width of french______-�-�r_�_t___._____- .� <br /> ff � <br /> Type of filter material---- Depth of filter material--------/_-___-----Total length----_--�_---_--3--_-__ b <br /> r <br /> Seepage Pit: Distance to nearest well-----kbo o .----Distance ffoundation-—3x,V' <br /> ___.Distance to nearest to <br /> _Linin material--S-1- ize: Diameter..__�f_ J <br /> Number of pits r g Depth------ -------- ---- <br /> 16- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------..LininEj`rfiaterial---.----..-__-----._---..-.---__----. <br /> Size: Diameter---------------------------- -------Depth------------- ----------------- ----------------Liquid Capacity -------- als..AA!� <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------ -----------= <br /> ❑ Distance to nearest lot line----- -------- -- --------------------------------------------------------------------------------------------------------------------------0 <br /> 1 <br /> Remodelinq�nd/or repairing (describe � �&4-� -- f- 4 S�-C-j <br /> � t t�- <br /> c�---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- <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 laws, and rules an egulations of the San Joaquin/Local Health District. <br /> (Signed)------------------------------------------------- -- - .. ... ........... _L/ ----------------------------------- ner and/or Contractor) <br /> BY ------ t'� - ------ -------(Title)----------- =9--�-t--­-- - ----------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 6e placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -ti ------------------------------- DATE �'" <br /> REVIEWEDBY-------------------------------------------- ----------------------------------- ------------------------------------------- DATE------------- ------------------------------------ <br /> BUILDING PERMIT ISSUED--------------- DATE--- -------------------------------------------------------- <br /> Alterations and/or recommendationsR-�---...--0-�.---- --•--------------•----------------------------------• - <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- <br /> --------------------------------------------- --------------- ---------------------------------------------------------- ----------- ----------------------------------- ------------------------------------------------- <br /> FINAL INSPECTION BY -,--S - -�,t,n�.._ ............. Date--- -- --1�--7- �`7-��.-._. -. - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ha:ellen Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />