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FOR OFFICE USE: <br /> --------------------------------------------------- -- <br /> APPLICATION FOR SANITATION PERMIT Permit No. .___.�f <br /> --------- -------------- ---------------- ---- (Complete-in Duplicate) 7 <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 /> l�DDREg �n - � ---------------------- - <br /> JOB ADDRESS AND LOCATION_ _ _ �=-7?'�_ - ------ -- - �� -- �� l' <br /> Owner's Name-A ' /l - <br /> r... 1 , : ;- ------ -------------- -------------------------- Phone <br /> Address y �4 ------------- -------­----- ----- <br /> Contractor's Name-- -a. .------..__..... Phone I <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E❑ Motel ❑ Other ❑ l <br /> Number of living units: Number of bedrooms -..L.- Number of baths J-.-- Lot size --_-�1.!�l ------------------------------- <br /> Water Supply: Public system ❑ Community system E] Private N Depth to Water Table 3.,?r- ft J <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam [N 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: <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 /> Disposal Field: Distance from nearest weJ_X.q. ---Distance from foundation---ZA_t.......Distance to nearest lot line_- -__..----- <br /> Number of lines.-_.-/------------- _-------------Length of each line__...2,_y--..... ..--.......Width of trench__,)-.Y._v--...________------ <br /> S Type of filter material-��--------------Depth of filter material-----Y ''-........Total length-_��_'-------__ -_-____-_----.- <br /> e{Pit: Distance to nearest well...-i�_'_-.......Distance from f undaticn--rd_�__--__.Distance to nearest lot line_ rV <br /> V Number of its-__ JJ ..__=-Linin material___. Size: [ er_e ..._ ----- <br /> Number -------------------- <br /> p F g <br /> Cesspool: Distance from nearest well ----------------Distance from foundation.-- ----------- ..Lining material-.-.--------------------..----__-----. <br /> ❑ Size: Diameter- -- ---------- ---- -.Depth--------------- - --------------------------------- Liquid Capacity---------------------- -----gals. <br /> I Privy: Distance from nearest weft--------------------------------------- --------Distance from nearest building---------- --------.-----____---_-__----. <br /> ❑ Distance to nearest lot line --------------------------- - - ----------------------------------------------------------------------------------------------------------- <br /> Remodeling <br /> ----- ------------------------Remodeling and/or repairing (describe):--- ----- -------------- ---- ------------------------------------------------ ---------------- -------- ----•----------------------•--•--- -- - <br /> --•--•---------------------•------------------------------ --------------------- ----•------------------------•----------------------------------------------------- ---------------------------­1------- --------------- <br /> ---------- ------------- - ------- -----------------------------------------------------------•--------------------------------------------------------------- ----------------------------------------------- ------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County El <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------- -- '----. (Owner and/or Contractor) <br /> By:------------ ------ --------- ---- ------------------------------- ------------------------------------- -(Title)---------------- ------- ... -- ------------- <br /> 4_r <br /> ------------ <br /> (Plot plan, showing size of to , location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-_ - r ----------------------------------- -------------- DATE-----'7-.."-L-,?..... 7----------- ----- - ------ -- <br /> REVIEWEDBY---- ---------------------------------------- -------------------------------- --------------------------------------------- DATE-------- --------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------- ------------------------- -------------------------•--------- - ---------------------------- DATE----- ------------------------------------------------------- <br /> Alterationsand/or recommendations-------------------------- ------------ - ------------------------------ ------- ---------------------•----------- ----------•-------------------.------------ <br /> ---------------------------------------------------- --------------------- <br /> FINAL INSPECTION BY Date_ - /-'G�- - ----------•------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Ifosslton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1..67 Vanguard Press .j +... s <br />