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FOR OFFICE USE: <br /> 3a----------- ! <br /> -�-------- --��--- - Permit No. ....1.�_�•�CI <br /> -------- --------------- ------ <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------------- (Complete in Duplicate) <br /> Date Issued --- <br />-------- <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 work herein described. <br /> This application is made in compliance with County Ordinance No. 549. (� <br /> --.-----•----------------•-•---------------•------------..- <br /> JOS ADDRESS AND LOCATION._._....----��--�-�- --- - - -------••---- ---•...---------------------•--•-------- <br /> Name_____-..__- - � Phone.............. <br /> -_---------- <br /> Owner's <br /> Address.- lJ- ./---- _; <br /> ---------------- <br /> . <br /> -----•------ --------------------------------------------- <br /> i r <br /> Contractor's Name ------ --------------------••-----------------------._...------•-- Phone--H e <br /> Installation will serve: Residence [!]Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: .___ Number of bedrooms .�-- Number of baths -2--.. Lot size ....____�....._x__Z`:------------- <br /> _---------------- <br /> Water Supply: Public system 2— Community system ❑ Private ❑ Depth to Water Table _Y.S ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe []— Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) 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 Tank: , Distance from nearest well----------------- from foundation.______•.-..______-Material---------.---__-_______.___________-.--_--______- <br /> ❑Lc`Xi1T' '`f No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity------------------ <br /> Disposal Field: Distance from nearest well __wP_�t_f�._Distance from foundation-----/.`_____._.. Distance to nearest lot line_- ------------ \ <br /> Number of lines-----------�------r_ --____--_Length of each line--------- -----.Width of trench----..--1!!_-------------------- <br /> Type of filter material--- <br /> ---------Depth of filter material-----1 -------------Total length--------- ."----...-------------------- <br /> Seepage Pit: Distance to nearest well____lvby --____Distance from foundation---- b ---..___.Distance to nearest lot line---S-_-______- � <br /> [._ Number of pits--------/------------Lining material____ct"e-------Size: Diameter-----A' ."_---___.Depth-------- ----------------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material_.__-_-_._-______--_-__-_______--_-_ <br /> I ❑ Size: Diameter-------- ----- Depth---------------------------------------------------Liquid Capacity_.--_---------------------gals, <br /> Privy.; Distance from nearest well --------------------L____-_______-_-___________Distance from nearest building-----------------------------------------. <br /> ❑ Distance to nearest lot line---------------------------------------- ----------------------_ ----------------------------------------------...._------------------- <br /> r Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------•-- --- ­--------------------------------------------------••----------------------------------------------------•------------------------------------- <br /> 1 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 /> (Signed)------------------ —-------- ------------ --------------------------------------------------------•------------(Owner and/or Contractor) <br /> Sy:------------ --------'=------- =- ---------------------------------------------------(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 /> i APPLICATION ACCEPTED BY_ � �-- -- - -----------------------•---•----------- DATE----__-- <br /> --.z --------------------------------------- <br /> REVIEWED <br /> /-------------------------- <br /> --'------` -�-- --- - -------------- --- <br /> REVIEWEDBY------------------------------------------ -------------------------------------------- -------------------------- --••---- DATE----------------------------------------------••------------ <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------•------------------------ DANE--------------------_- ------------------------------•------- <br /> Alterationsand/or recommendations--------------------------- ------------- -•-------••----------• ---------•------------------------------------------- ------------------------------- <br /> . <br /> I <br /> �, �--- --ice - <br /> FINAL INSPECTION BY:--------`---- ` Date. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soul American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E9-9 FEvIBEC E-99 F.P=.2M 6-60 - <br />