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1-UKOF -K..t USE: <br /> ----- <br /> _--_______ ___ ____ __________ ______________________ APPLICATION FOR SANITATION PERMIT Permit No. !.____�.. •. <br /> ✓ (Complete in Duplicate) <br /> -----� - ---�-------------------------------------------- This Permit Ex fres 1 Year From Date Issued Al � 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. i <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATIONIX -• � �� =r ------ -------------__----------- <br /> Owner's <br /> -------------_-•-•-------Owner's Name..... ---- ------------- Phone-----------------=----•-•-••-••-•-- <br /> �1,�--4---------- --------------------•--------------------------------------------................ <br /> Contractor's Name__ +'^- =--------------------------------------------------------------------------------------------------------------------- Phone............................... <br /> tnstallation will serve: Residence_] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ._-_-- Number of bedrooms ----[--- Number of baths A_._. Lot size ..._.���`___�............................... <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 7d-_. ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam W Clay ❑ Adobe❑ Hardpan <br /> Previous Application Made: (If yes,date-----------_--------) No Eq New Construction: Yes P� 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__4! ---••Distance from fpunclation,10-_---------M t rial__.-____...............:. ...... <br /> ------------ <br /> ( No. of compartments-----''>__________________Size_3.&� : _____.__.__-Liquid depth.......:.--____.______-_-Capacity_ p�.......... <br /> Disposal Field: Distance from nearest well-47P-___ .._Distance from foundation j,�...1.o..______..Distance to nearest lot line.47_.._..._ <br /> Number of lines.._.____ ____ _ ______ Length of each line___ P___-___________..Width of tr�nch.� �_�___________-_--_.-_ <br /> Type of filter me, eri� <br /> ----Depth of fitter material---/.r ."---------Total tang#h__� - ;=`-••--------------- <br /> Seepage Pit: Distance to nearest well.___-__-_____________Distance from foundation-------------------Distance to nearest lot line................. <br /> ❑ Number of pits----_----------------Lining material-----------------------Size: Diameter-----------------.-----Depth---------- ...................... <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material..................................... T <br /> ❑ Size: Diameter---------------- ------------------:--Depth----------------------•----•-----------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well__ ----------------------------------------------Distance from nearest building <br /> ❑ Distance to nearest lot line--------------------------------------------------------•----•---------------------------------•---•----•---------------------------------- <br /> Remodeling and/or repairing (describe):------------------------------•----- ----•-•---------------------------------------•----------------••-----------•------•-•--..-------------•--------- <br /> i ----•--------••-------------------------•----------•-.-------------------------.....-.------------------------•----•-•--------------------•----------•-------------------------.----------------------------------------- <br /> ----------------------------------------------------------------..------------ --...------•-----------•---------------•----------•-•----• is <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 laws, and rules and regulatio s of the Sad Joaquin Local Health District, l <br /> i <br /> (Signed)••-- •--- .....?,, <br /> -------- ._....------•--------------------------------------- ... .-••---(Owner and/or Contractor) <br /> B :-•------•-.......•-- • •-•-• ----- Title ------------------- ----- <br /> (Plot plan, showing size of lot, location of system in relation-to wells,'buildings,-etc.,-can-be placed on reverse side).­ �_ <br /> FOR DEPARTMENT USE ONLY Y <br /> APPLICATION ACCEPTED BY_ --- DATE-#�__f,�. " ----------...------•----•--------------- <br /> r - <br /> REVIEWEDBY----------------------------------------- ----------••-------------------------------------------------------•------...------- DATE <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------- 1 <br /> --------•-------------------------------------------------------•---••----------- DATE----------------------------------------------••---•--•-----• <br /> Alterations and/or recommendations:------------------------------------------ ---- ---------••---•-------------------•-••-•-•----•--•-•--........................................................ <br /> ---------------------------------------------____________________________________________________________________________________________________________________________________________________________________•____________ y <br /> ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ j <br /> ______________________________________________________________________________________________________________________-----.-.______..__________...--_-.---_______________----_.-•_----___._._.-..____-____-_._-...____._..__.. <br /> --------------------------------_________-------------------------------------------------------------_-------------------------------------------------------------.-.---_.__.___-____---.__--_.____..___--.-_-__.____-._. <br /> • 1 <br /> FINAL INSPECTION BY:_. .-. Date__/ _'�6.-`� ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 wear Oak Street 124 Sycamore Street 205 West 91h Street <br /> i <br /> Stockton,California Lodi,California Manteca,California Tracy,California t <br />�, EB 9 REVISED B-B9 7M 5-61 ATLAB <br />