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OR OFFICE USE: <br /> -------------------- <br /> 16------------------ . <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> --------------\�_,2v,0 --------- <br /> ------ (Complete in Duplicate) <br /> ----------I--------------------------------- ---------- This Permit Expires I Year From Date Issued 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. 49. <br /> ..... .... --------------------------------------------------------------------------------------------------- <br /> JOB ADDRESS AND LOCATION----- 4_19 <br /> Owner's Name-------------- -- ----------------- '-/ ----------------- <br /> --------------------------------------- -- - Phone--- --------------------- <br /> Address................................... ---------- - --------------------------------------------------- ------ ------------------------------------------------------------ <br /> Contractor's Name.------ -----------­------------ ;7-----;W---------------------------- Phone..-?-� <br /> Installation will serve: Residence ❑—'Apartment House E] Commercial Ej Trailer Court El Motel [j Other E] <br /> Number of living units: __/__ Number of bedrooms --2--Number of baths _/.--- Lot size -------- -_-__--__-._-_-_ <br /> Water Supply: Public system [Community system E] Private n Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam E3---Clay Loam F-1 Clay F] Adobe E] Hardpan <br /> Previous Application Made: (If yes,date---_-___,_-___--) No E] New Construction: Yes El No E] I FHA/VA: Yes F] No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: T_ <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'J <br /> ----------------------------------------------- <br /> El No. of compartments_... ---------...........Size___.----_______--_.___ . ___---Liquid depth...___.__..._.. -Capacity.....___--------- <br /> Disposal Field: Distance from nearest well----f7�...Distance from founclation..�_-_-_ -------Distance.to nearest lot line_____-__._. <br /> 0 � <br /> Number of lines______ .--Length of each line____ji�-----------------Width CLtrench-------2., <br /> ��._-.---.-___ <br /> Type of filter material-_ Depth of filter material--- ......_...Total lIngth------- ---------------------- <br /> I iAq6� o I <br /> Seepage it: Distance to Pearest IWO----------------- ----Distance frVm fouriclation-t.................Distance to nearest lot line------s7, e�... \K <br /> Number of pits-------- ------Lining material _o_��_ __Size: Diameter__'—�;:3 ��`------Dept h----- ------........ lz� <br /> yi�* <br /> Cesspool: Distance from nearest well-----------------Distan;e from foundation- -----------------Lining material_ - ---------------------------- r <br /> ❑ Size: Diameter__-.. . - -----—--------:Depth----_-------- ------------- ----------------Liquid Capacity-.--------------------------gals. )l, <br /> Privy: Distance from nearest well---------------------------------------------.___Distance from nearest building__--_-__________________--. \ <br /> ❑ Distance <br /> uilding------------------------------------------ <br /> Distanceto nearest lot line-------------------------------------------------------------i-------- ---------------- ------------------------------------ --------------- <br /> Remodeling and/or repairing (describe)---------- ------ <br /> Z5 ---------- <br /> ----------4� <br /> ___;----- <br /> ------------------------------------------------------------------------------------------------ <br /> ----------------------------------------------------------�r,_------------------------------------- -------- <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 rulel-)ind regulations of the San Joaquin Local Health District. <br /> zo"! <br /> (Signed)_---------------------_---- -------- <br /> -------------------------------- ...�(O nerod/or Contractor) <br /> ------- --- ----------------------(Title)---- ------ --- ---------------------- ----------- <br /> By:---------------------------------- ------- <br /> (Plot plan,.showing size of lot, location; o�sys;e7W, in r-, zifi-.on to Wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----------------oee 7, <br /> a000-------------------------------------------------------------- DATE--------- -- ------------ <br /> REVIEWED <br /> ---------_REVIEWED BY---------------------------------- -------__-------------------------------------------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED----------------------'---- -------------- ---------- -- -- -- -- D--A---T-E--------------------------------------------------------------I---------------------------------------------Alterations and/or recommendations:_-i- --- �Z <br /> -------------- ------------------I------- ------- -----------------------_---------------------- -------- ---------------------------------------------------------------- -------- <br /> - <br /> --------------------------------------------- <br /> ------------------------=-------------------------------------•----------------- ------------------ ---------- ------------------------------------------------------------------------------- -------­----------- ------- <br /> ------------------------------------------------------- ----------------------- ----------------------•----- ----------------- -------------------- --------------------------------------I-------------- <br /> ------------- --------------------------- ------------------------------------ ---------- ----------­_­------------------------------------------------------------- -------------------------- ---------------- <br /> FINAL INSPECTION -------------- ------------------ Date------- ice --------------------------------- <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 Manteca,California Tracy,California <br />