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----------- ---------------------- <br /> ---------..--------------.------------------- AMICATION FOR SANITATION PERly t Permit No. J.,/ -..-- <br /> ------------------------------ --------------------- (Complete in Duplicate) <br /> .__._-. This Permit Expires 1 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. 549. <br /> JOB ADDRESS AND LOCATI ---------------------------------- <br /> ------------- -------------- --- --------------------- --------------- <br /> p <br /> Phone------------------------------------ <br /> Owner's Name------------ <br /> Address----------------------- - � oContractor's Name----- ---------- ---- --- ---- <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __f.... Number of bedrooms -- _ Number of baths ... __ Lot size- -5il-t- <br /> Water Supply: Public 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 septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tari Distance from nearest well_.--------.------Distance from foundation--------------------Material___________-___-__---___.__.-.--.._._..______.. <br /> No. of compartments-------------------------1 Size-------------------------------- depth--------------------------Capacity-----------•----------- <br /> Disposal Field: Distance from nearest well_ Q__.Distance from foundation-___;_____..Distance to nearest lot line---- <br /> Number of lines-_________---____- ____-Length,,of each line_________________-_---__.-.Width of trench.__;-.___�.--____________._ <br /> Type of filter material____.5 :__.Depth of#liter material_.___.��'-_____..Total length--___--sa��_-�--------------------- <br /> Seepage Pit: Distance to nearest well___ ___-Distance from f u'dation_.-,37_ ---_-.Distance to nearest lot line____-.'-_--_.-- <br /> of � � <br /> Number of pits------`__._-_.-__.Lining material-______---Vle-'-Size: Diameter___ --__-...._Depth.___._._ <br /> Cesspool: Distance from nearest well---------.----.--Distance from foundation--------------------Lining material------------------------------------- <br /> El <br /> _________.- -____❑ Size: Diameter------------------------------------Depth----- ----------------------------- ---------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well----------------------------..___-____-__--_Distance from nearest building----------.------------------------------- <br /> F1 <br /> .--.___- ._-_._.❑ Distance to nearest lot line------ ------------------------------------ - ------------------------------------------------------------------------------------------ <br /> Remodeling and/or repairing (describe):-----' ice :--- -- <br /> --------------------------------------------=---------------------------------------------------------- ­_--------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- <br /> I hereby certify that I h ve prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and les and regulations ol the San Joaqui L7'- <br /> -------- <br /> o�caI Health District. <br /> _ �:___ �// ___( caner and/or Contractor) <br /> (Signed)----------------------------------------- - --- --- --------------------- <br /> ----------------------- <br /> ------------------ - -- - - <br /> - -------- ----- - --------- <br /> By: ' (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------------- ---- -- <br /> --------- ----------------------------------- <br /> REVIEWEDBY----------------------------------------------------- ----------------------------------------- DATE-- <br /> BUILDINGPERMIT ISSUED-------------------- ---------- ---------------------, -------------------------- DATE.- ---- --- ---------------------------------- <br /> Alterations and/or recommendations------------------------------------------------------------------------------ - ---------------- ----------------------------- <br /> .. <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------•- ------ ---------------- --- --------- ---------------- ----------------------------- ---------------------------------------------------------------------- --- ------ <br /> _ ----------------------------- ----- ----------- ---- ----- ---------- --------- ---- ---------------------------------- -...--------------- -------------------------------------------- ......... <br /> FINALINSPECTION BY--- -- ----- ------------------------------------------------ - - Date------------ -------- ------ ------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />