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rUK Ut-HCt USt: <br /> ------------------------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. 1. --------------- <br /> - -- -------- -- ----------------- ----------- --------- (Complete in Duplicate) <br /> Date Issued <br /> ___________________________________ __________________ This Permit Expires 1 Year From Date Issued <br /> ___ <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 /> JOS ADDRESS AND LOCATI � ' <br /> Owner's Name----------- ----------- ------------------------------------------------- --------- - Phone----••------------------------------ <br /> Address------------------------ <br /> = �] - -------- ----------------------------------------------- <br /> Contractor's Name-•-- --•--•-- --1------------ ---- X --------- Phone <br /> Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: j.___ Number of bedrooms __-41_ Number of baths _J_-_ Lot size'____________ __ . __________..___-- <br /> Water Supply: Pubfic system ❑ Community system ❑ Private PS Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam X' 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 sepfic tank or cesspool permitted if public sewer is available within 200 fee+.) <br /> Septic Tan : Distance from nearest well-----------------Distance from foundation--------------------Material------------------------ _._._______.._.________. <br /> No. of compartments--------------------------Size--------------------------------Liquid de p�h--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well. .-Distance from foundation____;' ___._.Distance to nearest lot line----____--- <br /> Number of fines---------------- -----------Length,of each line---------------------._------.Width of trench.__________._ <br /> Type of filter material___._✓,_._e __:_De T th ofilter material--__ ________________________ <br /> .__� Total length---_____c�S� <br /> p � - g <br /> Seepage Pit: Distance to nearest well.... ---_Distance from�fpu`ndation---J-0_1------Distance to nearest lot line------- <br /> Number of its____.`_..__. fr p <br /> p ._._.__Lining material---------- -Size: Diameter.___�� <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------.----------------- --_-_______ <br /> ❑ Size: Diameter--------------------------- Depth-------------------------- ---- --------Liquid Capacity----------------------------galls. <br /> Privy: Distance from nearest well________________________._.-__-________-______Distance from nearest b0cling---.------------ ----_-------------- ---. <br /> ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------- ------------------------------ <br /> i <br /> Remodeling and/or repairing (describe:...... Li[t. 3 <br /> -------- 3--------------- <br /> ----------------------------------------------------- - ----------------------------------------- <br /> ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ <br /> I hereby certify that I h ve prepared tcation and that the work will 6e-,done in accordance with San Joaquin County <br /> ordinances. State laws, and les and re:;L2 <br /> ulthe San JoagMs Local Healfh"Districf. <br /> Si ned __ __ ___ _________ _____________ _ weer and ar Contractor( 9 -------- / I <br /> --- - ----------------- <br /> BY•-------------------------i�=---------- ------ -- ------.(Title) ------ <br /> ------------- -- -------- ------------------ ------- --------- ---- <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 -- - --- -- ---- ----- DfAE <br /> REVIEWEDBY---- ------ ------------------ --------- -- -------------------------------------------------------------------------------- DATE----- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------._ DATE--- - ---------- --------- -------------------------------- <br /> Alterations and/or recommendations:----------------------------------------------------------••--------_-------------- -- <br /> --------------------------------------------------------- <br /> -----•-•-----------------------•------------------------------------------------------------------------------------------------------------- - ------------------------------------- <br /> -------------------------------------------------- ------- --------------------------------------------------------------- --------------.-----------.------------.---.------------------...------------------------ <br /> -----•-------------------------------------------------• ------------------------------ -------------------------------------------------------- -------------------- --------------- ----------- --------------------- <br /> FINAL INSPECTION BY--- ------------------------------------------------ Date - -- - - ---- ---- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazellon Ave. 300 West Oak street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> I <br />