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FOR OFFICE USE: <br /> ------------------------------ --- ------- <br /> -------- APPLICATION FOR SANITATION PERMIT Permit No. 4,12 <br /> ---------------------------------------............ (Comple+e-in Duplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued ✓�_=_p? _ . <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. &.2 <br /> JOB ADDRESS AND LOCATI N;2 <br /> Q.7 •_-----— <br /> Owner's Name-_.._ / ------------- Phone------------------------........... <br /> Address. ------------------------------------- ------- --------------------------•-•- <br /> Contractors Name------ - -- c ---- -------- --------------------------------.-- Phone------------------------------------ <br /> Installation will serve: Residence [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 ❑ Community system ❑ Private [Depth to Water Table ------ - ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam M"'Clay Loam ❑ 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: y <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well----- -----------Distance from foundation----.---------------Material ------------------_.-._---.----_______--.-----. <br /> ❑ No. of compartments-------- ----------------Size-------------------- -----------Liquid depth--------- ------ ---- Capacity------ --- ------ ----- <br /> Dispos field: Distance from nearest well_ Distance from foundation----/_o..........Distance to nearest lot line-------------- <br /> Number of lines-------I--------_ ______________Length of each line-- _1d_p___...___.._...Width of trench.Z.�__-__.--.-----_---------- <br /> De th of filter material------19- ---- -Total length-_--1._ _ <br /> Type of filter materiaL__._._._,�! p . <br /> Seepage Pit: Distance to nearest wel#-----------...........Distance 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----------- ----------------gals. <br /> Privy: Distance from nearest well---.-- ------------------___-------- --- --Distance from nearest building----------------------- <br /> ElDistance to nearest lot line ....................... ------- ------------------------------------ -------------------------------------------- ----------- ------ --- <br /> Remodeling and/or repairing (describe}_ ::.._- ---------- ----- - --•---•------------------ -------------------------------------------•---- <br /> ---------------------------------------------------- <br /> - - -- --- - ----------------------=----------------------------- <br /> --------------------- ----------------------------------------------------------------------------------------------------------r- - ------------------------------------------------- ---- --- <br /> I hereby er 'fy that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, St to ws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------ --------------------- __ ------ ------ - - - ----- - ------------------- -- ----- -- - - ----- <br /> and/or Contractor) <br /> ________________ -----_ _ <br /> (Plot plan, showing size of lot, locat on of sy m in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. . ----- ---- ----------------------- _ --------- DATE... -----� <br /> REVIEWEDBY---------------------------------------------- ------------------------------------------------- ------- --- ------ ------ DATE--------------- ----------------- <br /> BUILDING PERMIT ISSUED-------- -- ---------------------------------------------- ------------------- ---- ------ ---------- DATE----- <br /> Alterations and/or recommendations:------- ---- ........ --------------------------- --------------------------------------------- --•--------•------- ---------------------•----•-------------- <br /> -------------------------- ------ -- ------------------ --- -- --- ------------------------------------------------------------- --------- - --------- --------- <br /> FINAL INSPECTION BY:- Date_ ._�_ ._ ._-�t- _. - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ha:olron Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi. California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br />