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FOR OFFICE USE:' <br /> -------------------------- --------- - <br /> 4,140 APPLICATION FOR SANITATION PERMIT Permit No. �5�.................. <br /> -- --------------- --------------------- &� <br /> ------------------- ------------------- (Complete in Duplicate) Date Issued <br /> ---------------------- -------- --- --- ----- -- This Permit Expires I Year From Date Issued <br /> P <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 /> _ 2 1 <br /> ........... X& --------------------------------------------- <br /> JOB ADDRESS AND LOCATION ------------ - ----------------------------------------------------- <br /> Owner's Name---------- ------------- -------- Phone__'14 <br /> --- ------------- ------ --------------- -- --------------------------------I--------------------------------------- ------------------- <br /> Address------------------------------ --------------------t---------------- -------------- ------------------------------------------------------ <br /> IfI2­ <br /> ------------- ---------- <br /> Contractor's Name_ -- ---- ---- - - -------------- - -- -- ---- ------------------- ------------------------ Phone__';/2..------- <br /> Installation will serve- Residence [impartment House E]' Commercial E] 14railer Court E],' Motel ❑ Other 0 <br /> Number of living units: --- Number of bedrooms Number of baths Lot size ----------------- <br /> Water <br /> - ------------- <br /> Water Supply:' Public system El Community system E] Private Zr'bepth I to Water Table !� ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam E] 1 Clay Loam [3 'Clay 0 Adobe Er-lHardpan ❑ <br /> Previous Application Made: (If yes,date.-,- No 2--New Construction. Yes ❑ No. g—IFHA/VA: Yes [] No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No.selpfic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Disposal <br /> Tank: Distance from nearest well____-_..____-l`__Distance from foundation--------------------Materl al------------- ---------------------------------- <br /> & No. of compartments----------------------�_,Size-----------------------------I---Liquid dep�h------------- - - --------Capacity------ --- ---- ------- <br /> Disposal Field: Distance from nearest well-,,'.!-. "__-!Distance from foundation--------------------Distance to nearest lot line--_--___....._.. <br /> Number of lines----- ______________________(Length of e"achl, -_Width of trench.________1�22.31---------------- <br /> Type of filter material----a!:_VA��.VJD,pth 8_f_`filt'er 'rn1ateriaI__/_d__"--------Total length------ ----------I--------- <br /> Seepag Pit Distance to nearest well./,65.-4..........1Dis`t`a6`ce from foundation---13 _---._-_.Dista nce to nearest lot line__.__§�---------- <br /> ning' r�aferial_ _Size: Diameter--- ----D,pf h.........a�z :g <br /> Number of pits-___,2------------Li -----------/------------ <br /> Cesspool: Distance from nearest well_--_------- _Distance from founda'fion--------------------Lining material--.____-..-.---._-__--.-_-----------. <br /> ❑ Size: <br /> aterial------------------------------------- <br /> Size: Diameter------i-------�n----------------------Depth--------------------------- ----------------- -----Liquid Capacity.....----------------------.gals. <br /> I <br /> Privy: Distance from rea" rest'well--------------------------------------------------Dist ance from nearest building-._._._..___..______.___._._____._.__._._. <br /> 171 Distance to nearest lot line-...__--------------------------------------- - ----------- ------------------- -------------- ---------------------------------- -------- <br /> I ------- <br /> Remodeling and/or repairing (describe)-_ --- --- - -------- <br /> a_op�l ---------- <br /> ---------------- --------- -----------7 ---- ------------------------------------------ <br /> ------------------ --- --- --- ----------------------------------------------------- <br /> ------- --- -- - ----------------------------------------------------------------------------------------------------------------------- <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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> --------- ---- ---------------------------------- (Owner and/or Contractor) <br /> (Signed)------ <br /> �a i laced on reverse side). <br /> By:------------------------------------------------------- - - -------------- - ---- .-------------------------(Title) -- -------- <br /> (Plot plan, showing size of lot, loe"afion o;f1systern in relation f wells, buildings,.etc., can be p a <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY......"-------------- <br /> BY......I--------------- _Z�------------------------- ----------- DATE------ ------------------------- - <br /> REVIEWEDBY----- ----------------------------j -I-------- ----------------- --- - ---------------- DATE------------------------------- - ---------------------- <br /> BUILDING PERMIT ISSUED---------------- --------- DATE------------------------------------ ------------------------ <br /> ------ ------------------------------------------------------------ <br /> ------------------------------------ <br /> Alterations and/or recommendation ­P�14 --------- <br /> -----------------------------------------------------------------------I----------------------------- ------------M�;----------------------------- ----------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------ ---------------------------------------------------------- ---------------------------------------------------------------- <br /> ------ ----------- -------------------- ------- -- ---------- ------- - - ---- - - ------- ----------:------------------------------------------------------- --------------------------- ---------- <br /> ----------------------------------------------------------------------------------------------------------------------------------- ----------- ----------------------------------- -------- ----------------------- -------- <br /> FINAL INSPECTION BY:............ -- ------------ Date-- ----- 10491A-------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazollon Ave. 300 West Oak Street 124 Sycamore Street 205 West,91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy, California <br />