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j FOR OFFICE VSE: -SvIl� <br /> - - -------------- <br /> - ---- ------------ <br /> APPLICATION FOR SANITATION PERMIT Permit No. .. _ - <br /> ...--- - (Complete•in Du`pli ' tel <br /> _.-___.._ <br /> _ ._...-----__.._._--__.._.... .-_ This Permit Expires 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 compliant .with unty Ordinance No. 549. <br /> k <br /> JOB ADDRESS AND LOCATION.r. ------- -- -------; <br /> --------------------------------- -------------------------------- <br /> Owner's Name -------------- ------------•---------------------- <br /> ------ -- ------------------- ---- - -- ---------------------- Phone <br /> Address------g1 - 2 --- ------- .... ------------------------------------------------------------------------------•------------------•- <br /> Contractor's Name.--- `- .. A --------------------------------------------- Phone.2v <br /> Installation will serve: Residence Apartment House ❑ t Commercial E] Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _. ----- Number of bedrooms".=_ ." Number,of bafhs _______ Lot size __: --- ________________ ________________________________ <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Deptn to Water Table _._.._ _ ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Graver❑ Sandy roam 0_ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date__................7'No ❑ New Construction: Yes [5—No ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS- <br /> (No septic tank or cesspool permitted if ptablic`sewer,is available within 200 feet.) <br /> Septic Tank: Distance from nearest Di`stan�c-�e from foundation---JA-_____: Ma`erial ---------------- ----------__-____�___.____. <br /> [� No. of compartments__.__.- Size/4�I--t-- .. -r___-_Liquid depth-:. _ _.._... __-__..Capacity_/SG�-- <br /> r Disposal Field: Distance from nearest well_7a. ......Distance from foundation_'-5._/_-__ _.Distance to nearest lot line__k-__`_____- <br /> ` Number of lines ____------------------ -Length of each line--re,-�------------------ \ <br /> -Width of trench--�-f------•------------------ <br /> Type of filter mafierial__� `� __Depth of filter material-_/9_"/_----------Total length-_.. _`}�------____.____________ <br /> Seepage Pit: Distance to nearest well.,.__.________`.-_--Distance from foundation__________________.Distance to nearest lot line.______-._______ N <br /> ❑ Number of pits... ........... --Lining material---------------------- Size: Diameter.----------------------Depth_------------------------------- <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 /> F1Distance to nearest lot line ----------------r------------- -- - --------------------------------- -------------------- ------------------------------------------------ <br /> Remodeling and/or repairing (describe):------------------ -- --- ------------------------------------------------------------------------------------------------------------------ ----------- <br /> 4 - <br /> ------------------- ---------------------------------------------------•----- -------------------------------------------•-----•----------------------------------------- --------- <br /> ---------- -------------------------------------------------------- <br /> r 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 <br /> /rules and regulations of the San Joaquin Local Health District. <br /> (Signed]- � 7 'l _ Gl Owner and/or Contractor) <br /> BY = ------------------- --------­----------------------------(Title). - <br /> -- <br /> (Plot plan, showing sire of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> p FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ---------- ------------- DATE------ ---- ------------------------- - <br /> REVIEWEDBY------------------------- -------------------- --------------- DATE------ ------------------------ <br /> BUILDINGPERMIT ISSUED----- -- ------ ------ --------------------------- ---------------------------------------------- DATE----- -------------------------- <br /> Alterations and/or recommendations------------------... --------------------------------------- <br /> --- <br /> -IF------- <br /> - � - - <br /> - <br /> �`- - ------ -- ` -- ------- --------- --- -------------- <br /> ------------------------- ------- ----------------------------- ---- -------- ._.._.-- <br /> FINAL INSPECTION BY:. -----------­-- ------- - -------------------- Date..`. � ---------------- f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton 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 /> k � <br />