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APPLICATION FOR SANITATION PERMIT Permit No. ..... <br /> o <br /> (Complete in Duplicate) <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 e [ <br /> This application is made in compliance with County Ordinanc �No. 549. <br /> JOB ADDRESS AND OC ION__ a V - <br /> --------- <br /> Owner's Name--- - ....... ------=------------ one--------------------------- <br /> --------- <br /> Address <br /> ------ <br /> Address------------------ -- --------------------------------------- ------------------ <br /> - - -------------- ----------------- --=-------------------------------------- <br /> Contractor's Name------ - •---- ------- ------- ---- 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 1_4 --------------------------------- <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 Clay Loam ❑ 'Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No R1� New Construction: Yes ❑ No &' FHA/VA: Yes ❑ No Zf __ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) <br /> Sep c Tank: Distance from nearest well_______________ <br /> Distance from foundation--------------------Material-___-----.----------___________--____---._.._-.-. <br /> Nco art s____----- --------- <br /> Size----------------- ---=----- -Liquid depth--------------------------Capacity-----------------•---- <br /> Dispos <br /> j field: • -Distance from nearest we Distance from foundation_f`Q-------�Distance to nearest lot lin__�,.__.._ ! <br /> Number of iines---- --- ------ -------- Length of each line_?,O _-.Width of trench_______ _ _____ _ <br /> Type of filter material_ ,: Depth of filter material__/s '�--__-_--.-Total length___..,/r ----------------------- <br /> 3 <br /> Seepage Pit:. Distance,to nearest well_ __________ <br /> ------------------Distance from foundation--------------------Distance to nearest lot line_-_-_-__-____.._ <br /> ❑ Number of pits----------------------Lining material----------------------.Size: Diameter------------------------Dept h--------------------------------- <br /> k <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 /> -Distance sta _nce onearest lot line------------------- ------------------------- -----------------------•------------------------------------------------ <br /> ---------------------- <br /> Remodel in and or repairing des S4 <br /> - - ---- - -- -- -•-- s:�,� �.L - ------- -------- <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 regula ions of the San Joaquin Local Health District. <br /> 4(Signed)---- --------•--- - ----------------------- -------------� Contractor), <br /> By:----------------------------•- ------ --------- ------------------------------------------(Title) i ► ------------- <br /> (Plot plan, showing size of lot, loc n of system in relation to wells, buildings, etc., can be placed on reverse de). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- --------------------------- - ----- -- - - ------ DATE' r°' <br /> _ <br /> 7 <br /> REVIEWED BY -------------------- - �:_ <br /> DATE ---.----, <br /> BUILDING PERMIT ISSUED------------------------------ <br /> _- ----------. DATE----- i <br /> ndations---_-----_------ <br /> -- ---------------------------• -----------------•----------- ------------------ ------- ------------ -----------------------------------------------•-------•----------•--------.--.-------------------------•---------- <br /> ------- <br /> Alterations and/or recommendations <br /> -------------------------------------------------•--------------------------------- <br /> ------------------------------------------------------------------------------------------------------------ -------------------- _. <br /> ----------------------------•----- --------------- --------------------------•------------- --------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:.. --------- <br /> ----- Date ----=-------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814'North "C" Street <br /> Stockton, California Lodi, California Manteca;California Tracy, California <br /> ES-9-21x1 , Revisea 1-57 F.P,CO- <br />