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APPLICATION FOR SANITATION PERMIT Permit No. . _S_ - d <br /> (Complete in Duplicate) �r <br /> Date Issued <br /> = 4 <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. 54 <br /> i <br /> --- - ---------------JOB ADDRESS AND LOCATION---------- --- <br /> - - <br /> - = - <br /> Owner's Name------------- ° ---------------------------- - --- ---------- - ------------ - Phone_ -- <br /> - �----- <br /> R <br /> Address ------ --- <br /> -------------------------- <br /> Contractor's Name------------------ -- - - o------------ <br /> ------------------------ ----------------------------------------- Phone.------------------------ ------ <br /> Installation will serve: Residence (�' Apartment House E-] Commercial E] Trailer Court E] Motel ❑ Other ❑ <br /> Number of living units: �`Number of bedrooms ---/--- Number of baths ___/__ Lot size ___L� __1 _',fes____________________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑� Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No a New Construction: Yes ❑' No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> a {No c to or cesspool permitted if public sewer is available within 200 feet.) <br /> Sept'e <br /> Septic ank: nce from nearest well----- Distance from foundation_ ______.Material <br /> - __ ------ <br /> fompartmenfs- --------- --------------Size---------------------------- --Liquid depth--------------------------Capacity---•------------------- <br /> Dispos i d: '4&rrce from nearest well-________-_-----Distance from foundation--------------------Distance to nearest lot line________________ <br /> Number of lines------------------.-_---- <br /> ----------Length of each line------------------------------Width of trench <br /> T of filter material-----------------------__Depth of filter material-----------------/....Total length---------------------------------------- <br /> Seepage <br /> ---______-.___________--____________- <br /> f See a e Pit: Distance to nearest j__----`:___________Distance fro found; •on___)40---------Dista ce to nearest lot line-_��-- <br /> Number of pits-_ - Lining material_ f DiameterDepth_____ <br /> ---------------- <br /> Cesspool: Distance from nearest well_____..___------Distance from foundation_..____------_-.__.Lining material____________________ <br /> El <br /> Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well_____________________-._____---__------_-------_Distance from nearest building------------------------------------------- <br /> F-1 <br /> --_- ______._________---__-_--------__--. <br /> ❑ Distance to nearest lot line--------------- - <br /> ---------- ------=----------- <br /> 0-1 Remodeling an car repairing ascribe):-----'° A�.___�__ _�------ ----- �_"__ I. - ----------------- <br /> ! <---- <br /> -------- - -- -------- ---- <br /> I hereby certify that l 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 /> {signed}-- - f ------------------------ -- <br /> �. (Owner and/or Contractor) <br /> By=------------------------=------••------------------------------------------------------------------------------------------------(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 <br /> APPLICATION ACCEPTED BY--------- -- --- --- --------------- ---------------------------------------- DATE <br /> REVIEWED BY---------------------------------------- <br /> ---------------------- ------------------ ----------------------------- DATE------------------ <br /> .-- - <br /> - -- -------------- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------. DATE <br /> ---------- -------------- <br /> A terations and/or recommendations-------------------------- ------ <br /> ---------------------------------------- --_------------------------- <br /> --------C , r't '------------rR rs <br /> , , 7 --- <br /> ------------ - -------------------------------------------------------:-----------------------------...----•- <br /> ---------------------------------------------------------------- <br /> ------------------ -- <br /> ----- <br /> /f �/fA5 <br /> FINAL INSPECTION BY:_.__-_______-__v_ <br /> ---------------- - -------------------- Date- -------- ----------- -- -------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M 8-51 Revised W-2100 <br />