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FOR OFFICE USS: <br /> --------------------------------------------------------- <br /> ------------------------------- --- - - - - - - <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> - ---- ------- - -- <br /> --------------------- �/ (Complete in Duplicate) j <br /> --- --- --- -- - ---- - ----- -- <br /> - Date Issued ._�-_..___._'__.. <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.f <br /> JOB ADDRESS AND L9CATIION_. --------------------------- <br /> Owner's , <br /> Name----- --------------------------------------------------------------- Phone------------------------------------ <br /> Address + i - - -�? '� 1 -•----------------------------•------- <br /> Contractor's Name......, -i -----------------•---------••-----------••-------- -------•-------•- --•------•-•------------------- ---------- Phone----------------------------------- <br /> Installation will serve: Residence 8 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: I----- Number of bedrooms ./----- Number of baths -1----- Lot size __ 4 -e-________________________________ <br /> Water Supply: Public system ❑ Community system ❑ Private [t Depth to Water Table _ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 4 Hardpan ❑ <br /> Previous Application Made: (If yes,date------_-------------) No ❑ 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 /> ❑ No. of compartments--- ----------------------Size-----------------------•--------Liquid depth--------------------------Capacity-----------•----------- <br /> Disposal Field: Distance from nearest well__ -----Distance from foundation__-1.q_1--------- to nearest lot line_c�_--_____-_ <br /> Number of lines---- _____..._.._._____----.__Length of each line-----3_ ------------------Width of trench--A /-----._________--------____ <br /> Type of filter materialA_-__h-------------- of filter material----l_�_____________Total length---- �!____--___.____-_-____---_ <br /> Qe4 -Pit: Distance to nearest well_j,/__4 __- -.-___Distance from foundationl�+---------._.Distance to nearest lot line------------- <br /> ' -------Size: Diameter_�a". ~It----Depth------- ----•--------------- <br /> ❑ Number of pits_-/--_--.-._......Lining material,,�__,_y-_. � <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining material----------------------.-------------- 0 <br /> ❑ Size: Diameter------------------------- -----------Depth-------------------------------------- ------------Liquid Capacity--------------------.------gals. <br /> l <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> r_1 Distance to nearest lot line---------------- --------------------- ----------------------------------------------------------- --------------- ------------- <br /> Remodeling and/or repairing (describe):-------- ----------------------------- -----------------------------------------------------------------------•--------------.-------------------------- <br /> -------------•-------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------- -----------•------------------ <br /> ---------------------------------------------------------------------------•-----------------------------------------------------•------------------------------------------------------------------------------ <br /> ---------------------------------------------•----•------------------------------------•------- -•------------------------------------------- - -----------•-------- --.---- ------- <br /> I hereby certify that I havejan <br /> ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, St laws, nd ruler latioof the San Joaquin Local Health District. <br /> (Signed) - -- - ------------------------------- --------------- - -- ----------------- Owner and/or Contractor <br /> By:----------I------------------------------------------------------------------- ------------------------------------------------(Title)-------------------------- ---------..._ <br /> (Plot plan, sho i`g size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> �_, FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----,r10! ' a� _____ _ " " <br /> - DATE ' <br /> REVIEWEDBY---------------------------------------- ------------------------------------------------------------- ------ DATE----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------- ---------------------- <br /> Alterations and/or recommendations------ ---------------- -----------------------------------------------•----------------------------•--------------------- -----------------------------•------- <br /> --------------- -------------------------------------- --------------- -----------------------------------------------------------......................----------------------------------------------------- <br /> 1-1-----------------------------------------------------I-------------------------------------- --------------------------------------------------------------------------------•--------------------------------------- <br /> ----------- ------------------------------------------------------------ -------- ------------------ -------------_---------------------- --------------------------------------------------------------- <br /> ----------------------------------- -------------------------------------------------- ---------------- ------------------------------------------- ----------------- ----------- ------------------- <br /> 6 <br /> ------------ ----- <br /> FINAL INSPECTION BY:-- -- .-�. . , :: " Date- --�`------------------ ------------------------------------------ <br /> SAN <br /> ---- ----------------------SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California i Y Manteca,California Tracy,California <br />