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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------- ---------------------- ------ ------- <br /> ........................ <br /> ----------------- --- ------ (Complete in Duplicate) 0 �6 <br /> Date Issued <br /> -.-_--------------------- .------------------ --.__._.__ This permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wcgrl�herein described. <br /> This application is made in co m liance with County Ordinance No. 544. t fo� <br /> JOB ADDRESS AND LO ATI NQ '` <br /> --- ---- - ----------- - - - -------------------- - -- ----------- Phone------------------------------------ <br /> l/ �- 'c--'+� -�-^�-. --------_ -----------------------•-------------------•------------ <br /> Address-----------•-------- ------- ----- --------,-- -- --- --------- --•---------------�--- ---•------�------------- - <br /> Contractor's Name--------- - -- --- ---- Phone.---------------------------------- <br /> ---------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---/ Number of bedrooms __Number baths-2-7-rot size -/4;!?_04 <br /> Water Supply: Public system ElCommunity system [I Private pth to ter Table -------- ft. + ` 6-....I <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑1 . <br /> Previous Application Made:. (If yes,dote--------._,___-----1 No ❑ New Construction: Yes ❑ 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 nk: Distance from nearest well®____ _. -------------- ' <br /> ._._Distance from foundation___/P -__.Material___.-_ - - ------____. <br /> 10 <br /> No. of compartments----- --------....Size���"5e'Vi'x,5_/Liquid depth----�----- --------Capacity---/-2_0Q_ <br /> Disposa field: Distance from nearest well----r-?a-----Distance from foundation-----`_d-_......Distance to nearest lot line_�,__._____- <br /> Number of lines----------�.-___- Length of each line------r0-- ------Width of trench-.-- .------------------- - <br /> Type of filter material____-_S-_-�y----____Depth of filter material--------- &_-.Total len9th__jiZ44AV_"`------------------------ <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 /> ------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material__-.___....____.____.-_----.-_.______. <br /> ❑ Size: Diameter------ -------------------------------Depth-------- ------ ---------- - ----------------Liquid Capacity a1�.1` <br /> Privy: Distance from nearest well--------------__.--------.-----------------------Distance from nearest building--------------------- ;-'__.._-----.--. <br /> El --------------------------Distance to nearest lot line ---------------- --------- --------------- - -------------------•--------------------------- ----------------------------- ---- ----------- <br /> A.4 <br /> Remodeling and/or repairing (describe)--------------------------------------- ---------------------------------------------------- ----------------------------------- --- k <br /> lf T -------------------------------------------- ----- <br /> -------------•--_------------------------------------------------ <br /> r <br /> ---------------------------------------------------------------------------------- <br /> __.____.____P•}`!___________I_______________________________ ________ _ _______________________________________________________________________________________________________________________________________________ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinance$, State41aws, riules and regulations of the San Joaquin Local Health District. <br /> Si ned end/or Contractor) <br /> ( 9 )•---------------- ---------- - ----- ------------ --------------------- -•------------------ <br /> -------- --- - <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 /> -------------------- DATE. -l3- <br /> APPLICATION ACCEPTED BY__ .1 - --------------------------------------- <br /> REVIEWEDBY---------------------------- -- - ---------------- - ---------------------- --•---------------------- --------------------- DATE------------------------------------------------------- ---- <br /> BUILDINGPERMIT .ISSUED--------------------------------------- ------------------------------------------------------------ DATE------------------------------- ---------------------------- <br /> Alterations and/or re.commendations------------------------ ------------------------------- ----------------------•------------------------------------------------------- <br /> -------------------------------------------------- ---------------------- - -------------------------------------------------------------------------------------------------------- ----------•--- <br /> I -----•---- ------------------------- -------------------- ---------- ---------------------------------------------------- <br /> I . t <br /> ---------- -------- ---------------------- --- - <br /> n-- <br /> FINAL INSPECTION BY:..... Date----------A_. /,? ------ -------------- <br /> SAN JOAQUI 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 /> F.P.0 O. <br />