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rVKUrEIC-t U5E: t <br /> ---------------------- <br /> --------------------- APPLICATION FOR SANITATION PERMIT Permit No. �.�L�1-�• <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 Heal+h District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance 549. <br /> JOB ADDRESS AND L T�N_ ( � —. - ---- - - - = ---- ---- ---------------------------------------------- <br /> Owner's Name---- - - Ph <br /> -----------------.,""' one------------------------............ <br /> Address------------------------ '-- -• ---•- - ----------- <br /> -- - ------ _ <br /> ---------- <br /> Contractor`s Name_-. <br /> Installa+ion.will',servo:. Residence Apartment ouse El Commercial El Trailer Court E] Motel El Other <br /> - r C. <br /> =Number of living,nits: -------- Number of bedrooms - f�.. Numberaof baths -/-----,Lot size __± <br /> Water Supply: Public;system� Community_;system ❑ Private ❑ Depth to Water Table7-57+. <br /> t s . <br /> Character of soil to a dept of�3 fee+:* Sand ❑ .Gravel ❑ Y Sandy Loam ❑ ;Clay Loam ❑ Clay ❑ adobe❑. Hardpan ❑ <br /> Previous Applica+ian'Made: (If yes,date_..___.___r�],"NoNew:Construction: Yes ❑ No FH /VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank:or cesspool pertt itted if public sewer is available within 200%feet.) y' <br /> Septic Tank: r Distance from newest well___-_E____-__Distance founcla�tion______�-'°-�.Material..-,_____ -______________________--_--_______- <br /> ❑9`�CIS No.: of compartment-s-------------=--- --------Size--------------------= - Liquid depth 'Capacity <br /> Disposal Field: Distance from nearest well-"- _ _-------Distance from foundation--------------------Distance to nearest lot line______-__________ <br /> ❑ Number of lines----j--------------- -----------Length of each line-----------------------_------Width of trench <br /> Typ;e of filter mat#vial---------- ------ ----Depth of,filter material----------------------- length---#-------------------------------------- <br /> Seepage Pit: Distance to neares#.well._ p1 '--'---Distancerom undation--10._ _. ista/ce to nearest lot line__1.5--`_--_ <br /> Nu�ber of its Cllr- linin material_. . --.-Size: Diameter-_ <br /> p g !-. -. Depth r�� <br /> ❑ Size: Diameter----- - -----------= ' -----------De fh------------------------------ I----:-------- {---Liquid ty------------------------- - <br /> Cess ool: Distance from nearest well.-'_:___--__--_,Distance from foundation---------------1:___.Lining materia' <br /> �-------�----------------Distance from nearest buildingCapaciy_-_--_--------------------gals. <br /> --g------ <br /> Privy: Distance from nearest well;-__------------r_._._ <br /> k - - --- ---------------- ...... <br /> -- -- <br /> ❑ Distance to nearest lot rne`ol F <br /> Remodeling and/or repairing (descriG I t:_.- <br /> ---------------------------------------- ------------------------ I------------ --------------- ----- ------------- ------------- <br /> ----- - <br /> - ------------- <br /> ------------- <br /> - ---. -- ----- . ------ �-----------------�------------------------------------------------------- <br /> - - ,. Lica+ion and That t wor will be done I---------------------------------------------------------- ---- <br /> ---------- ---- -- ---------- p p--- ------ i <br /> l herebycertifythat I heve a ed this a.p k '� n accordance with San Joaquin County <br /> ordinances, State laws, and rut an iegulation5" the San Joaq "n ocal Health Dis+rict. <br /> (Signed) i ------ ------------------ ---------------- caner and/or Contrac+or) <br /> l <br /> By:-----------------------t---------- -- ----- i .: 1 - - ---------------------(Ti+le)---------- k <br /> (Plot plan, showing size of lot, to ion of system i efation to wells, buildings, etc., can be placed Ureverse side). <br /> M <br /> FOR DEPARTMENT USE ONLY <br /> � d <br /> APPLICATION ACCI=P7ED BY----------- ­_�_­- ----- ---------------------------------------------------------- DATE-------r��= "� <br /> REVIEWEDBY------------- ---- -- _... ---------------------------------------------------------------------------------- DATE------------- <br /> BUILDINGPERMIT ISS I ED--------------------------------------------------------------------------------------- ------------- DATE--------------- <br /> ------------- <br /> Alterations and/or recommendafioris:------- ----------------- <br /> -----"- ----------------=------------- -------------- <br /> Crnt <br /> ysem' t ------------------------ <br /> * _ ----------------- -------------- <br /> ------------------------- <br /> -,KetFINAL INSPECTION BY:.- -------------------------- --- Date-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E,Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,Californih <br /> r.P.CO. <br /> k - r <br />