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FOR OFFICE USE: L / <br /> Permit No. _.— ------- <br /> -------------------------------------------------------- f <br /> -- --_-- ----- ----.-- APPLICATION FOR SANITATION PERMIT ,3/ / <br /> --- l / <br /> _ (Complete in Duplicate) Date Issued -------_ ja___---- <br /> This Permit Expires l Year From Date Issued <br /> _._ _4. . .. ............ <br /> -- -- ---- ___ _%k <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 r�inance No. 544. <br /> JOB ADDRESS AND LOC TION_ __ _____ ------------- <br /> . _ - <br /> c c <br /> Phone------------ <br /> Owner's Name _"_ ------- -- - -- <br /> Address-------- <br /> ---- - - - ---------- ------------------•---------------------•-•----------•---------------------- --••------..._ <br /> • ------ 2- ----------- -------t <br /> Phone,?,., <br /> Contractor's Name---- ------------------- <br /> Apartment House ❑ o mercial ❑ Trailer Court ❑ Motel ❑ Othe <br /> Installation will serve: Residence ❑ p <br /> Number of living units: _ --_ Number of bedrooms _T�_ umber of baths -_ - <br /> _ Lot size - •---•------- <br /> E a <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 [3 Clay ❑ Adobe Hardpan [Ii i NoX <br /> Previous Application Made: (If yes,date----------_---------) No New Construction YesX No ❑ <br /> FHA/VA: Yes ❑ <br /> x <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public, sewer is available within 200 feet.) <br /> i Septic Tank: Distance from nearest well._l _ -Distance from foundation._._�L.O.---.Material------------------------------------------------- <br /> No. of compartments_ Size---••-----------------------•---Liquid-depth -------------- -----Capacity ; <br /> --------------• ------ Q� <br /> !! ��✓------`.Distance to nearest lot line-- <br /> Distance Field: Distance from nearest well__l_�'�.-_Distance from foundation..-- Width of trench__.AV_.`�------------------ <br /> Number of lines___--._..__ Length .of.each line_______�b------td------ <br /> s , Type of filter matenalt; Depth of filter materia!___ __ ______�.Total length_______� ---•----------•_---- <br /> 216.(.. <br /> Seep a a Pit: Distance to nearest well---� -0-----Distance from foundation___A,,_0. ..Disst IFric __ nearest to lin _ <br /> I Linin ma.�� ize: Diameter epth <br /> - Number of pits----- -- - -- -- <br /> ( Cesspool: Distance from nearest well-----------------Distance om foundation___________________Lining material___-..._________----- els. <br /> ❑ Size: Diameter--------4----------------------------Death-----------------------------------------------------Liquid Capacity----------------------------9 <br /> _-- Distance from nearest buildin <br /> �-`�'�priv Dis#ante from nearest well--------------------------------- g----- ----------- ------------- --------� <br /> Y A ------------------------------------------------ -----------------•--------------- -- <br /> ❑ ---------------•-------------­------------ <br /> - ----------­---------------- <br /> to nearest lot line ------ <br /> - ----•--•--••------------•---•--------------------------- <br /> Remodeling and/or repairing (describe):_____--_-------____________--___.__-_____._ ------------------a <br /> s <br /> --------------------------------------- <br /> ------------••-----••----- <br /> -••-----•-------•----------------------- ---------------------------------------- <br /> ----- -------------------------------------------------------------- <br /> - ---- ---------------—----------------------�p--------------------• ----------------- ------------------------------•---------•---------- --------------- <br /> 4 ( I hereby certify that I have prepared this application and that the work will be done in <br /> 'accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ti <br /> .. ----------------------------{Owner and/or Contracto`. <br /> (Signed)_ _ <br /> -------------- --- <br /> (Title) <br /> ) -------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse si e. <br /> I FOR DEPARTMENT USE ONLY s <br /> DATE------------------------------------------------------------ <br /> APPLICATION <br /> ATE---------------•---•-------•-------------------------------- <br /> APPLICATION ACCEPTED BY------------------ -------- --------- DATE <br /> ----�- <br /> - --- -- ---------- ---------------------- <br /> I REVIEWED BY----- --------------------­ ­-- ----- ------- DATE---------------------------------------- <br /> _. <br /> BUILDING PERMIT ISSUED •----------- ----- - <br /> sAlterations and/or recommendations-----------------------------------------------------------_--------------•- <br /> ------------------------------- ---------------------•-•------------•------ -------- -------------------- <br /> --- --- -------------- -- ------------------- <br /> - <br /> -••--- -------------------------- ------- ------------------ <br /> FINAL INSPECTION BY----------- --------------- <br /> Date__.----------.... . " � -------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Sycamore Street 205 West 9th Street <br /> 130 South American Street <br /> 300 Wast Oak street 144 <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E15-9 REV,9E0 11.59 F.P•Co'ZM 6•ao <br />