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FOROFFICE USE: <br /> ----------------- - --" ------------------"" - ------ APPLICATION FOR SANITATION PERMIT Permit No. <br /> --------------------------------------------------------- <br /> (Complete in Duplicate) <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 construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> ��rQ- ---- <br /> II <br /> JOB ADDRESS AN CATI N__ I i <br /> Owner's Name----- ' � ------ ----- <br /> Address -~ i •--------------------------------------------•--•------------------------ t <br /> Contractor's Name --------------•-•-------- Phone-----------------------='----------• ; <br /> ----------- - - <br /> Installation will serve: Residence [ impartment House ❑ Commercial ❑ ,Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of livin6­uriifs _ Number of bedrooms�-" Number of baths _aZ_ Lot size 1_ ----------------------- ----------- <br /> Water Supply: Public system ❑6 Community system [] Private Depthf to Water Table X041 <br /> Character of soil to a depth of 3-fee :-iSand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ . Y <br /> Previous Application Made: (lf yes,date------- ------------J No &'-'"New Construction: Yes ❑ �No [�HA/VA: Yes ❑ 'r No's— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:! .F R <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Se tic Tank: r Distance from nearest well_________________Distance from foundatioiquid depth""Material--------------------- <br /> No. <br /> .-- ---Capacity______..___ ; <br /> No. of compartments--------------------------Size----------------- <br /> Dist <br /> isfance from <br /> ance <br /> Dis -------- <br /> Disposal Numaberofolines earest well------------- -Depth of each I ne�ation-_-- _ ----=__.__..Width oftfrenchest lot line:_- __-"-_..__- <br /> Type of filter material.........................Depth of filter material-----------------------Tota! length---------------------------------_-_____._ r <br /> �. $ / r ! Lr <br /> Seepage Pit: Distance to nearest�e11 --:-----Distance­fr fou dation__-s� --.---.Distance to nearest lot lin�__.c <br /> [ Number of pits.__.-- ._."__-___-_- Lining material__ -Size: Diameter____y�__.t?..--------Depth__ _______"__"_"__------ <br /> Cesspool; Distance from nearest weft-----------------Distance from foundafion--------------------Lining material------"-------------.___..__.._-__---6C5 <br /> ❑ Size: Diameter ------------------------------Depth------ ---------------------------------------------Liquid Capacity------------------------------gals. {1, <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearesf building____-----__________.___---_' <br /> ❑ Distance to nearest lot line----------------------- -- <br /> /'t <br /> Remodeling and/or repairing (describe):-------------4£��--�---�- - -� �1-- ------------------------ ---------------- - --------- ---------------•----------• � t <br /> ----------•----•--------------------------------------------- <br /> t <br /> ------------------------------------------------------------------- -------------------------- <br /> `- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------ ---------------------------- <br /> f ! <br /> ------------- - -------------------------------------------------- ---------------------------------------------------------------------------- <br /> -- ----------------------- i <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 r es and regulations of the San Joaquin Local Health District. <br /> r <br /> (Signed) -- ---------------------•I (®� rector) 1 <br /> ( )- ,/�•l — Cont......................: <br /> $Y:-------------------------- -------------------------------------------- -------- - - - - - ---�---Title <br /> (Plot'plan, showing size of lot, location of system in relation ells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BY - =-------------------- = ------ DATE----------------- -------------- ---------- --------------- <br /> REVIEWEDBY------------------------------------------- - -------------------•------------------ ----------------------------- DATE------------------------------------------------------ ---- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------- <br /> ----------- <br /> Alterations and/or recommendafions------------------------------------------------ -----------------------------------.----------"-------------------------- ---- <br /> ---------------------------•----------------------•----------------------- -------------- ------------------------------3.._____... <br /> _-----------------------'—i- <br /> --------- <br /> .----•---------------------------------------- --------.---".---__.---------------------------------------._.-.._--------------------------------------------------.-------------------- --------------_--------------.-- <br /> _------------ ------------------------------- `, <br /> FINAL INSPECTION BY: ------ - ------- ---- �� Date.-------------------------. � ._ --------. I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - I l <br /> 1601 E.Harellon Ave. 300 West Oak Street + 124 Sycamore Street 205 west 91h Street I <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />