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FOR 6FFICE..USE: <br /> ------------------ --------------------- <br /> - -------------------------------- ------------------------ <br /> APPLICATION FOR SANITATION PERMIT Permit,No. <br /> ------------------ --------------------------------- (Complete in Duplicate) <br /> Date Issued 1-;2 <br /> -- --------------- <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 Ordinance No. 549, <br /> JOB ADDRESS AND LOCATION-----/7_3_2�-------4(!��--------------- -------�Fl------------ --------------------------------------------------- <br /> --- --------- <br /> Owner's Name ------------------------------------ P h o n e.i&Z -0 <br /> ------ ----- ---------:-. <br /> Address---------------- ---------- -----------------------1-1----------------i----------------------------------------------------------------------------------------------------------- <br /> Contractor's Name---------------------------------- ------------------------------------•------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence E] Apartment House E3 Commercial 0 Trailer Court X Motel E] Other L] <br /> Number of living units:(-_ Number of bedrooms ---------Number of baths -------- Lot size -------------------------------- <br /> Water Supply: Public system T%, Community system El Private E] Depth to Water Table -------- ff. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy Loam El Clay Loam 0 Clay [] Adobe, Hardpan E] <br /> Previous Application Made: (if yes,date---------r­--------) No [P—New Construction. Yes EJ No E] FHA/VA: Yes E] No Ej <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sep is T k: Distance from nearest well___-_______-__-_Distance from foundation---------_---------Material------------------------------------ - --------- <br /> No. of compartments-------------------- ----Size--------------------------------Liquid depth------------ - - ---------Capacity----------------------- <br /> ;Di posal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line___-__-------_-- <br /> Number <br /> ine----------------- <br /> Number of lines------------------------------------Length of each line-----------------------------.Width of trench.-------------.--------------------- <br /> Type <br /> rench---------------------- ------------- <br /> Type of filter material-------------------------Depth of filter material-----------------r,----Total length------------------------------------000-- <br /> S ep ge Pit: Distance to nearest well--- —---_---____-_Distance from foundation----LO-------- Distaniq to nearest lot line---1__�;--------- <br /> Number of pits-------/--------------Lining material----1ZQC-e___..Size: Diameter___--V - Depth------- --------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-------__---------.-_-----_----_.___ <br /> ❑ <br /> ateriai----- ------------------------------- <br /> F-I Size: Diameter------ - -------- ----------- -------Depth----- ----------------------------------- <br /> ----------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building....-.-__.._____---_--_-__----------__.... <br /> ❑ Distance <br /> uilding--------------------------------- ----- <br /> Distance to nearest lot line- . -------------------------------------------------- <br /> ------------------------------------------------------------------------------------- <br /> f-es <br /> Remodel;na and/or repa crib e):-_A_;:dV-------4�v ------ ---------�_ <br /> ------------------------------------------------------ <br /> --------- --------- --� "------------------------------------- <br /> -------- -- -- --- --------- ---- ------ - <br /> ---------------------------------- <br /> ------ ------------------------------------------ -----------•---------------------- •-------------------------------------------------------------------------------------------------------------------------------------- <br /> L 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. <br /> (Signed)-- -- - ------- -- - ------ ------------------------- <br /> ------------------------------- --------(Owner and/or Contractorl <br /> . ................... <br /> ------------------------------------- - ---- - - - ---------- <br /> By ----------------------------------------------------------------------------- ------ ---------------------------------------------(Title <br /> I <br /> (Plot plan, showing size of lot, location of system in relation',to wells, buildings, etc., can be placed on reverse side). <br /> ZOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- -------------------- --------------------------------- DATE-- 6(-- ----------- - --- <br /> REVIEWEDBY----------------------------------- .........__---------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------- --------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations--------------------------- - - ------------- ------------------------------------------------------------------------------------------------------------------ <br /> --------------------------- ---------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- -------- ------------------------------- <br /> ---------- ---------------------------------------------- --------------------------------------I-----------------------------------------------------------------• --- --------------------------------------- - - --- ----------- ------------------------------------------------------------------------------------------------------ --------------------- <br /> --------------- <br /> ------_------------ <br /> --------------- ------------------------ ------ ----------------------------- ------------------------------------------ -----------L--------------------------- ----------------------------------- ------------------ <br /> Date........ <br /> FINAL INSPECTION BY___________________ --- -------i�-�_ ----- �� --------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Maxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> F.R.CO. <br />