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FOR OFFICE USE: <br /> �- 'APPLICATION -FOR SANITATION PERMIT Permit No- __�_1. 1 <br /> -------------------- ------------------------------------ (Complete in Duplicate) r <br /> -- This Permit Ex fres 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 /> JOB ADDRESS AND ------------------------------------------ <br /> LOCATION___ -------- ----------------------------------------- ------------------------------------------ <br /> Owner's Name----- �°� r!>! L_ ; - Phone <br /> - ------------------ -------------------------- <br /> Address ----------------------------------------------------------------------- <br /> - <br /> 3 t f r � <br /> ContractorsName----------- -- -- - - --------•�---•'���-� -----tt.---•------------------- ----------------------------------------------. Phone----------------------------------- <br /> Installation will serve:. Residence ®Apartment House ❑I Commercial ❑ Trailer Court ❑ Motel •❑ Other ❑ <br /> Number of living units: __`.__ Number of bedrooms .3-- Number of baths__ Lot size _ _ __l.`F� ______________________________ <br /> 4,t ,P IL <br /> Water Supply: Public system Community system ❑ !Private ❑Depth to Wafter Table ��_ ft. <br /> Character of soil to a depth of_ 3 feet: Sand ❑ Gravel ❑ Sandy LoamE1 Clay Loam ElClay El Adobe El' <br /> Adobe � ardpan <br /> Previous Application Mader (If yes,date--------- ------- -) No p-- New Construction: Yes ❑ No 0- THA/VA: Yes [�No ❑ <br /> TYPE OF INSTALLATION 'AND SPECIFICATIONS: t } <br /> (No septic tank or cesspool permitted if public sewer is available within 200•feeth) <br /> Septic Tad::: Distance from nearest well_---------------Distance from foundation__._:__ ----------Material------_______-_-.------------------------ --___-. <br /> No. of 'Compartments....----------------------Size-------------------------- �_Liquid depth----------------`-*---- Capacity------ ---------------- <br /> Disposal Field:— Distance from nearest well.................Distance from foundation------------------�Disfance to nearest lot line----------------- <br /> �yt Number of lines-----------------------------------Length of each line---------------------.--------Width of trench---- --------:---------_---------- <br /> Type of filter material-------------------------Depth of filter material----------:------------Total length------------------------------------------ <br /> I or r <br /> Seepage Pit: Distance #o nearest well-------."'-'..______DistanceAlle <br /> fndation, ______.Distance to nearest lot line__.______.__ <br /> i T-eems-Depth_Number ofpits..._ '_____________Lining mate'rial___ Size: Diameter:.- .__ F/ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation___------___----____Lining material--------------.-------------------- <br /> ._ <br /> ❑ <br /> '� ___ -----Liquid Capacity Size: Diameter------- -------- ----------------- D�pth- ------------------------------------- -- q ----------•-•----•-•--------gals. <br /> Privy: Distance from nearest well ------ t_------ ----------_.-......Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line--.---------------- -- -- -------------------------------------------------------------- ------------------------- ------- <br /> Remodeling and/or repairing (describe):---------------- e G- ------------------------------------------------------- <br /> L, <br /> --••- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ <br /> i <br /> t <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 and regulations of the San Joaquin Local Health District. 5 <br /> (Signed)----------------------- / r' r� --------- ( or Contractor) <br /> y BY ---------------------------------------- - ----- - -- - -------- <br /> -----------------------(Title)--- ----------- ................... <br /> (Plot plan, showing size of lot, location of syste ' relation to wells, buildings, etc., can•be place' d on reverse side). <br /> lei <br /> FOR DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED BY--------------- - - ----------- -- ---------------------------------------- DATE------------- <br /> .REVIEWED BY-------------------------------------------------------------------------------------- ------------------------------------- DATE----------------------------------------------------------- <br /> BUILDING PERMIT ISSUED---•----------------------------------------------------------------- ---------------------------._. DATE-------------------------- <br /> . ---------- ----------------------- <br /> Alterations and/or recommen ati•on--------------- ---------------------------------------------- ---------------•-------------------------------------------------- <br /> � �.------ , - •--- ------114 --------------- ----------------------------------------- <br /> fr <br /> ----------- ------ ------ ------------- -------------------- ------------------------------------------------------------------------------------------------------------ ------------------- ---------------- <br /> FINAL INSPECTION BY:............�"<{-.__---------------------- - Date- ---------"� -���T�j�--------------------- <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1401 E.Hazellon Ave. 300 West Oak Street t' :124 Sycamore Street "` , 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F,P.0 O, <br />