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FOR OFFICE USE: <br /> ----- ------- --------------------------------------r.__ <br /> ------------------- ------ ------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .......... <br /> - -- ------- ------------ ---------- -------------------- <br /> (Complete in Duplicate) ..Date Issued <br /> --------------------------------------------r--------- <br /> A This Permit Expires I 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------- --- ---- --------------- - - -`---- <br /> Owner's Name------- --------------------------------------- --------------------------------------------------------------------- Phone-- ----------••-------------- <br /> ----------------Address------------ _/-- --------------------------- -------------------------------------------------- <br /> Contractor's Name------ = -------------------------------------------------------------------------------------------------------------------- Phone.................... ---_--------- <br /> Installation will serve: Residence EK-Apartmerif House E] Commercial E] Trailer Court E] Motel E] Other I-] <br /> Number of living units': _/---- Number of bedrooms--?... Number of baths ___L Lot size __Zl�--- ---------[---------------------- <br /> Water Supply: Public system 0'Community system R Private R Depth to Water Table ft. <br /> Character of soil to a depth bf 3 feet: Sand F] Gravel E] Sandy Loam E] Clay Loam F] Clay 0 Adobe B__I'arclpan E] <br /> Previous Application Made: I(If yes,date___________________) No KKNew Construction: Yes Ej No 0_.-FHA/VA: Yes E] No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well________________Distance from found&;on---------------:-_Material------------------ ------------------------------ <br /> . 11o. of compartments--------------------------Size---------------------------------Liquid clepth---------------------------Capacity.......... ------- <br /> Disposol (_field: r Distance from nearest well-- <br /> --------------Distance from foundation___.___._____-------Distance to nearest lot line____________-__-- <br /> Number of ;ines---------------- -------------Length of each .......Width of trench.-----7---- ------------------------- <br /> Type of filter material---- -----Depth.of filter mafer'SaI_____1_e----)------_Total length ------i------ _j <br /> Seepage Pit: Distance to nearest well.---'�'''" istance from fLndation----- -------Distance to nearest lot line_.____-____-_ <br /> 0 <br /> Number of pif�--------I-----------Lining mate ria L-R-4 Size: Diarneter-7 Depth-------4' -------•---------- G <br /> Distance from nearest well------------------Distance from foundation--------------------Lining matorial----------------------------o---------- <br /> ElSize: Diameter------- ------------------------------Depth------:------------------------------------ --------Liquid Capacity----------------------------gals. <br /> Privy: Distance-from nearest well--------------------------------------------------Distance from 'nearest i3uifd'ng---------------------------------- <br /> ❑ %Dist;nce to nearest lot line--------:-------------------------- - ----- -------------------------- <br /> -------------- --------------------- ---------- -------------- <br /> Remodeling and/or repairing (describe):----------------------------------- <br /> ----------------------------- -----------­------------------I----------------------------------1-1------------------ <br /> ------------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------I--------------------------------------------------------------------------------------.......I----------------------------------------------------- <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 la'ws,'and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) <br /> ----:--------I----------------- -------------------------- ---------------------(Owner and/or Contractor) <br /> By:__----------------------------I---------------------------------------------------------I---------------------------------- <br /> 17 ---------(Title)------------------------------- _ --------------- <br /> (Plot plan, showing size of lot, location of system in relation fd'wells, buildings, etc., can be.placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----------A ------ -------------------------------- DATE X_ <br /> ---------------- <br /> REVIEWED BY------------------------0--- ---------------------- DATE <br /> BUILDINGPERMIT ISSUED--=--------------------------------------- ----------------------------------------------------------- DATE-_:----------------------------------------------- <br /> Alterations and/or recommendations:-_______._ ------------------------- - ------ ------- ----------- --------------------- -----------------+„•-----_-._ --------- <br /> -------------------------------------------------------------------------1�- _ C <br /> ------------------------------ <br /> ------------- ------ ­-------------------- <br /> --------------------------- <br /> ---------- -- <br /> -- ---------- -- -------------------------------- --------------------------------------------------- <br /> ---------------------------- -------- ------------T------------------------ ----------------------------------------------- - --------------- - ------ --------------------------------- ----AA-- <br /> FINAL INSPECTION BY:.. - --- --- ----------- ---------- ---- ---------- Date-------------------------- -------------- -- ------------------------------ <br /> SAW.JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h street <br /> Stockton,California <br /> Lodi,California Manteca,California Tracy,California <br /> ES 9 REVISED B-59 3M 3-'63 F.P.Ca. <br />