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FOR OFFICE USE: c J 600q VJi 4W (f 2 ( ( <br /> -------..---------- ___-------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .r _a � <br /> ---- ---- --- --- <br /> ------ (Complete in Duplicate) 1 I -� <br /> __.___ This Permit Expires 1 Year From Date Issued <br /> Date Issued __ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construc and install the work herein described. <br /> This application is made im liarKe wit Courlty Ordinance No. 54 <br /> JOB ADDRESS A LOCATIO <br /> - -''r <br /> -- _ . �- <br /> Owner's Name--- -C -- ----.- Phone_----------------_-' <br /> - -------- ------------------------------------------------------ <br /> 2 <br /> Address 1`z�- - `=C ..f_ -`------------------------------------------------ <br /> Contractor's Name-------------------------------------------- --------------------- ------- ------------ ---•-- Phone................................... <br /> will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: J____ Number of bedrooms J____ Number of baths ----/_ Lot size ---------a� .....X.e-C <br /> Water Supply: Public system ❑ Community system 5�r Private ❑ Depth to Water Table _ _ 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 [f'' New Construction:- Yes E] No E] . FHA/VA: Yes [I No ❑ <br /> � fYJ a",,• ;'' i7 ;iy' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) . f� -7l <br /> Septic Tank: Distance from nearest well_1` _. Distan e,f found #ion ? __.Material_j`�-----------, � �------------<�` _` <br /> p 9!n ar <br /> +❑'� No. of compartments '�._ __. _ q p � � p y r <br /> p .� . Size. Liq, de th---_�- - -------------Ca acct --------------- <br /> Disposa Field: Distance from nearest well /KZ:r. .Distance from found on ��`-,�-_----Pistance to nearest lotline____n__._....... <br /> �' Number of lines.-_4_,-_. Length of each Width of trench------ ____ d <br /> Type of filter materia _4,1 ._kDepth of filter material-. . l------------Total length------------ ___ _ _____________ c7 <br /> 0 <br /> Seepage Pit: Distance to nearest well.- ------------------- from foundation....................Distance to nearest lot line-----..-_---__--. <br /> ❑ Number of pits------------.--------Lining material-----------------------Size: Diameter-------------------.---Depth_---.-----------------------.-- <br /> Cesspool: Distance from nearest well--:-_.___..__-__Distance from foundation--------------------Lining material___ __-.__-_ - .___.--. <br /> ❑ Size: Diameter---- ------ ---- ------------Depth------ ----- ------- --------------Liquid Capacity--------------------------..ga I s. <br /> Privy: Distance from nearest well--------------------_______________---________Distance from nearest building----------------------------------__---.-. C� <br /> ❑ Distance to nearest lot line------------------------------------------ ------------------------- ----•-------------------------•------------- --------------------------- <br /> Remodeling and/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 Sagoaquin Local Health District. �j <br /> 4. C41- C4'(Si <br /> (Signed) �, : -� - . - - ---- ___.____.__.(Owner and/or Contractor) S <br /> By:---------------------------------------------------------------------------------------------------------------------------------(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 /> APPLICATIONACCEPTED BY---------------------------- --------------------------------------------------------- DATE------------------------- --------------------------------- <br /> REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE-------_-------------------------_---------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------- -------------------------------------------------------------- DATE------------------------------ ------ <br /> Alterationsand/or recommendations:------------------------------------------------------------------------------------------------•-------•--•-------------•--------------------------.-------- <br /> -•-------------------------------------------------•-------------------------_----------------­­--------------------------------------------------•-------------------------------•--------------••----------------------- <br /> ------------------------------------ ----------------•--------------------------- ----------•------------------------------------------ ---------------------------•---------•----------•----------------------------------- <br /> -------------•---------------------------------- ------•-------- --- --------_-- --------------------------------- --------------------- ------------------------------•-•-•--- -------------------- ---------•-- <br /> FINAL INSPECTION BY------ -- --------•----------------------------- ----------- Date------------------ ------ ------- <br /> SAN 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 /> F'.P.co. <br />