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FOR OFFICE USE: \ <br /> 'If---- <br /> ------------------$ `' \ <br /> -�(�� __ 3_ - - APPLICATION FOR SANITATION PERMIT Permit No. ... !-�` .... <br /> --------------------------------------------------------- (Complete in Duplicate) �� <br /> --------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued' CAN 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 Countjy JOrdinance No. 5p. <br /> JOB ADDRESS AND CATI N..._.4.. .../ _____________ <br /> :`�11_ Z S <br /> Owner's Name--- - - - - - - ------- -- -- - ---- - -- ---------------------- - -- --------------------------------------- Phone---------•--K-A,_11--------- <br /> ........... ---------------- <br /> ------.- --`- <br /> Contractor's Name-- --------- --- ----------- -_---_ ----------------_------- ------ -_----------------------- Phone <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _/__ Number of bedrooms _ Number of baths _/__ Lot size -_-_--_- _ --•--------------- <br /> Water Supply: Public system E] Community system ElPrivate;KDepth to Water Table "ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0' Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) Nog 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 Distance from foundation_J_4�_�..... <br /> .Material_19 <br /> �' No. of compartments.._.__r��---------------Size__ _ SAX_ ._.__.___Liquid depth___�f_.. .----_._.__-Capacity.. 4._" " <br /> Disposal Field: Distance from nearest well--s.!-.Q__._.Distance from foundation_-,R.�........Distance to nearest lot line-------- _j_. <br /> Number of lines------- -------------------------Length of each line----LZ-1-----___--- ---.Width of trench--------- ------._---._.--.- <br /> Type of filter material___S-'.r/Q _ '__Depth of filter material--__).�__.__..Total length________________•_---.�7!_.f_..._.. <br /> YL i r <br /> Seepage Pit: Distance to nearest well__/Qd_-. ___Distance from foundation-.. `.t.__.___.Distanceto nearest lot line-` ........ <br /> Number of pits------ -____--_-Lining material___ _AI'__Size: Diameter___.._ .._____Depth_---.-i?_S__.-__-_._-_- J <br /> Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material_--_--_-_.-_--_-_-----------------. <br /> ❑ Size: Diameter------------------------------------Depth--------------------------------------------------Liquid Capacity--------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------.-----------------------.__._._---_. <br /> ❑ Distance to nearest lot line--- -----------------------------------------------------------•---------------------------N---------------------- <br /> Remodelingand/or repairing (describe)=----------------------------------------------------------•-------------------------------------------------•-•---•----------------•--------------- <br /> ------------•-------------------------•---------------------------------------•------------------------------------------------------------------------------- ------------------------------------------------------ ------ <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, Mala4Lles an regu ations of the San Joaquin Local Health District. <br /> (Signed)------- --------- ----- --- -------------=--- ---------------------------- -------------------------------- <br /> j----- <br /> (Owner and/or Contractor) <br /> By:------------------------------------------------------- - ------- ------------(Title)--- /r`.'I ----- ----------- --- - ---- --------- <br /> (Plot plan, showing size of lot, location of system in relation to well uildings, etc., can be placed o reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- ------------------------- ----------------------------------------------- DATE---------&=_S:74141 <br /> - - ---------------- <br /> REVIEWEDBY----- -------------------- ------------ ---------------------------------------- ----------------------------------- --------- DATE-----------------_-------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------- ------ DATE-------------------------------------------------•----------- <br /> Alterationsand/or recommendations------------------- --------------------------- ----------------------------------• --------------------------------------------------------------------------- <br /> '6_-`.` _.__.-!G'-. � _-_%�t____________________ _--__-__-.-•--_-_._-_-__-__-----._-__--___.___.______.______________._______________._.__.._._.__________..__. <br /> -------------------------- ----------------------- ------- -------------------------------------------------------------- --•--------•-- -----------•-----•------------------- <br /> --------------- ------------------------ ------------------•-------- --------------------------------------------------•-.------------------------------------------------------------------ --------.-----_----•---------_ <br /> ------------------------- ------- --------------------- -�----- ..-------------------------------•----------------•---------------....------------•--------------•------------------------------- -------- <br /> FINAL INSPECTION BY:. Date <br /> SAN <br /> 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 />