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FOR OFFICE USE: <br /> -•------------------------------------------------ <br /> APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> ------ ----- ---- ----------- ------ ............ (Complete in Duplicate) <br /> --- -- This Permit Expires 1_Year From Date Issued bate Issued <br /> r -- /qa--3� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wo�jrktrein described. <br /> This application is made In compliance with County Ordinance No. 549. j2n1.2 nf. <br /> JOB ADDRESS AND LOCATION. <br /> z _ <br /> Owner's Name- ---- '----------- _ Phone------------------------------------ <br /> ----------------------------------------------------------------------- <br /> Address ----------------------•-••------•-----------------------•-----------•--•----------------.--------------- <br /> Contractor's Name._ -:ee�pr -- — ---- -- ---------------------------- Phone----------------------------------- �N <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ <br /> Number of living units: ---1- Number of bedrooms .-Y Number of baths _1__- Lot size ------------------------------------------------__-_._--1 <br /> Water Supply: Public system ❑ Community system ❑ Private [ Depth to Water Table .--- ft. I'a <br /> 9� <br /> Character of soil to a depth of 3 feet: Sand E] 'Gravel E] Sandy Loam [Clay Loam ❑ Clay E] Adobe E] Hardpan ❑_ <br /> Previous Application Made: (If yes,date....--- ......--_)' No E].- New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <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 foundation____________-------Material -----_----___.-__----.----_-------.__-_-.__--. <br /> t <br /> ❑ No. of compartments------------- ----- -----Size------------------ _---------.--Liquid depth-------------------- - ---Capacity----------------------- <br /> Disposal Field: Distance from nearest well----- --------Distance'from foundation.--.-__._ '---._-___.Distance to nearest lot line------_--____--- + <br /> ❑ Number of lines-----------------------------------L ngth of^each line----------------------.------.Width of trench------------------------------------ <br /> Type of filter material-------------------------Depth of filter material_______-----_-----._-,.Total length__,___..._-----_-.----_--_-----__._--..-�, <br /> 1. <br /> Seepa it: Distance to nearest well-----_f��.' _ <br /> _- Distance from foundation !_�__� ---.Distance to nearest lot line---S-�__...- <br /> Number of pits_.i----/------------Lining material---;s-,R-r_-----_-size: Diameter-- ------DepA__:2- <br /> ---------------------------- <br /> Cesspool: <br /> .S'-------.--_-_-_ i <br /> - <br /> Cesspool: Distance from nearest well-----------------Distance from foundation____--------_------ Lining material_=._:.--�_ ----------------------- <br /> Size: Diameter--- --------------------- --------De th----------------------------------------------------Li Liquid Ca acit <br /> ❑ p q p Y- ----------------------gals. <br /> Privy: Distance from nearest well-----------------------------------------------_Distance from nearest building--_-...---_-------._-_--------------.---.. <br /> ❑ Distance to nearest lot line----- -------------------- ------------------------------ <br /> Remodeling and/or repairing (describe) <br /> ----------•-•-----•------------------------------------------- ------- ,.. xs - ->,- --- '��°--- ------------------- - - <br /> ---- ---------------------------- <br /> --------------------------------------------------------------------------------------------------- --- ------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that 1 have prep`a ed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules a ulations of the San Joaquin Local Health District, <br /> (Signed) ------- ------- -- ------- ------------------------------------------------ nd/or Contractor) I <br /> g - -- — 1 - _ rt <br /> (Plot plan, showing size of lot, ovation of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> ` DATE `' - = ._ <br /> APPLICATION ACCEPTED BY-- ---- ----------------------------- <br /> REVIEWEDBY----------------------------------------------------------------- ----------------------------------------------------------- DATE------ -- -------------- ------------------------ ------- <br /> BUILDING PERMIT ISSUED-------------- !----------------------------- ------------------------------------------------------- DATE--------------------------------------------- <br /> Alterationsand/or recommendations------------------- ----------------------------------------------------------------------------•------------------------- ----------------•------------------- <br /> ----------------------------------------------------------------------------------------- ----------- --------------------------------------•- ------•-------------------------------------------------------.------------- <br /> Ii <br /> ---------------------------------------- ----------•--------------------------------------------------------------------------------------- ------ ---------------- -------------------------- --------- --------------- <br /> ---------------------------------------- ----------------- -------- ------------ ----- ----- ------ - --- ------I-------- - ---------- ----- ----------------------------------------- ----- -------------------- <br /> I <br /> i <br /> FINAL INSPECTION BY------- - --- ----------- -- ------ Date.......I... --44-, --- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California i Lodi,California Manteca,California Tracy, California <br /> ta- <br /> 4 <br />