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FOR OFFICE USE: <br /> ---- - -- --- ---- ------ <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------------------------------------------- (Complete in Duplicate) Date Issued <br /> ......................................................... This Permit Expires I 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. 54.9. <br /> j Z7 <br /> JOB ADDRESS AND LOCATION---------------- ---------------_--' -i <br /> Name.__....----aJ Zr/z�/­`_C­6--------------------------------------------------------- --------------------------- Phone--------------------- L/-------- <br /> Address--/ <br /> ....A ------- .....L ....... <br /> --------------- --------------------------------------------*--------------------------------- <br /> Contractor's Name..._.. <br /> ....... - <br /> ..................................................................................................... Phone................................... <br /> Installation will serve: Residence Apartment House E] Commercial [-] Trailer Court [] Motel E] Other ❑ <br /> Number of living units: J----_ Number of bedrooms ......../Number of baths .1---- Lot size ------ I" <br /> .................... <br /> Water Supply: Public system El Community system Private [-] Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam M Clay Loam [] ClayZ_ Adobe ❑ Hardpan 0 <br /> Previous Application Made: (If yes,date----------- NoPi New Construction: Yes <br /> "Ed No Ej FHA/VA: Yes E] 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 C,_�-----Distance from foundation------LL Mat?rial.........--------------i;:7rf� <br /> No. of compartments-----:7�------------- a,--.Liquiddepths --------- <br /> Dis gsal Field: Distance from nearest well) Distance from foundation... —Distar)c <br /> nearest lot I' C'0 <br /> T ---------- <br /> -----------Length of each line.../t1 trench ------------------ <br /> Number of lines.-.4----------------- --- h <br /> --------- <br /> Type of filter mat e�rial... e_(Depth of filter material-------j Total length....__..... ....D....................... <br /> Seepage Pit: Distance to nearest well......................Distance from foundation....................Distance to nearest lot line_.._.._.._._..... <br /> ❑ <br /> ine--------------­ <br /> El Number of pits----------------------Lining material-----------------------Size: Diameter_-..._--_.------_-_.-._Depth--- ----------------------- <br /> Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material....__._._._._ --------------------- <br /> 0 Size: Diameter--------------------------------------Depth--------------------------------------------------..Liquid Capacity..----------•--------------gals. <br /> Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building------------- ---------------------------- <br /> r_1 Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------- <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, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> ----------------------(Owner and/or Contractor) <br /> (Signed,--------Lz__ --------------------------------------------------------------------------------- <br /> By:................ __< . -------------- -----------------------------------------------------------------(rifle)--------------------------------------------- - -------------- <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------------------------------------------------------ -------------_------ ... .............. DATE-------------- <br /> REVIEWED <br /> ATE................ --------------------------- <br /> ----------------- _��ATE `' <br /> BUILDING <br /> BY----------------------------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-----------------------------------------------------------------_--------------------- -- ---- DATE------------------------------------------------------------------------------------------ ............... <br /> Alterationsand/or recommendations:---------------- -_------------------ ---------------------- ------------------------------------------------------------------------------------------------ <br /> ---------------------------------------- ------------------------------------------------------------------------------------------------------------- ..................................................................... <br /> ----------------------------------------------------------------------------------------------------------------------------------...................................................... ----------- ------------------------ <br /> ---------------------------------­-- -------------------------------------------------------------------------- ........------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------I------------------ <br /> ---------------------------------------------------------------------- -- <br /> --- - ------------ <br /> FINAL INSPECTION BY:._-.-- <br /> - ------ _-----I-------------- Date------ -------- ----- - -- -- -------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> 9:9 9 REVISED 5-59 3M 3-'63 F.P.120. <br />