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qY� 111 4 <br /> , .k APPLICATION FOR SANITATION PERMIT Permit No. . _________________ <br /> (Complete in Duplicate) <br /> Date Issued /-.Q----,7L,.S74Z �. <br /> Applica;ion 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 /> . ---`�s- -----�--�---------- ' d - ------------------------------------------------------ ---- --- <br /> JOB ADDRESS AND LOCATION________.P <br /> , 1 <br /> ln� '-------------------- Phone-/�_q__ P-----�j <br /> sd _ _ <br /> Owners Name------/--------- ----- -----------•--••1 ��-----------•---------------- <br /> Address-----------------� - .� ------------- <br /> - --------- ----=----------------- -------- <br /> Contractor's Name____ ... <br /> --------------------------------------------------T--• Phone- !� �� �` <br /> i <br /> le IL- <br /> Installation will serve: .Residence 2"Apartment House ❑ Commercial :❑ Trailer .Court El Motel E] Other El. 1 .. <br /> Number of living units: __..---- Number of bedrooms . ...... Number of baths _1---- Lot'size ____-------------------------_------------------------------ <br /> Water Supply: Public system ❑ Community system 0�private ❑ Depth'to-Water Table-_# _' ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ j <br /> Previous Application Made: Yes ❑ No a New Construction: Yes•©!ro ❑ <br /> TYPE bF 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 /> ❑yam No. of compartments-------j---------------size- X3G--X-13---Liquid depth---_--Sly__ ...........Capacity......YOn--------- <br /> Disposal Field: Distance from nearest-well.___:.,7......Dista'nce from fcundationAl.r�_±___-_.Distance to nearest lot line_ir___6-------- <br /> _ <br /> Number of lines____________ ---------------------Length of each line----------L_�_._________-Width of trench..........2,__41-- --------------- <br /> Type of filter material-___ZA____A---__Depth of filter material_-_-_ length-----------a2-p__.................... T <br /> Seepage Pit: Di'stanc'e to nearest well----'—-----^____Dis ' ce from foun a 'on__-____fid R___------- Distance'to nearest lot line-----AAL'­ <br /> Number of'pits----------I----------Lining erial_-q�__ iz : Diameter-.-.---„5,.,5..........Depth_- r-112-�f7*-------------- <br /> Cesspool: Distance„from nearest well________________ Distance from fou tion...._.____.______--..Lining material___._.._-__-_______.____._____-______- V <br /> Size: Diameter--------------------------------- --- --__`_Liquid Capacity als. <br /> Privy:' Distance from nearest-well-..:........:...i_..____----___-----___..___--_._Distance•from nearest building------.---------------------------- - <br /> ❑. Distance-to nearest-lot line-~_~ ---------------------------------------- -----------------------'=------------------------------------------------------------ 1 <br /> f E I <br /> Remodeling and/or repairing (describe)----------------- ------ - --- ---------------_-... ......---...-----•---- -----------�- ..------... ------------------------------------- <br /> ' �I <br /> ---------------------------------------------•----------•------------•------------------------------•---•----- •------------------------------------------------------------------------------------------------------ <br /> -------------------------•-----------•------------------------------------------------------------------- <br /> - <br /> -••-•---------------------------------- •-------------= ': <br /> ---------------------------•-------------------------• --------------•----------------i-------•--------------------------------------------------------- <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, StateI ; and rules and regulations of the San Joaquin Local Health.District. <br /> (Signed) i ' __(Owner and/or Contractor) <br /> -----------•---- .� <- _ ----------------------------- <br /> By=---------------------------- ------------- = A � � �� _(Title)------r2: - <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 /> APPLICATION ACCEPTED BY DATE___4P m------------------------------- <br /> ------------------ <br /> .---------------------------------- <br /> REVIEWED BY------------------------------ <br /> r ------------------------------------------- DATE <br /> BUILDINGPERMIT ISSUED-------•-•- ----•----•--------------------------------------------------------------------------- DATE---------A'------------------------------ <br /> Alterationsand/or recommendations:---------------------------------------------------------------------------------------------------------__.................------------------------------ <br /> -----•--------------------------------------------------------------------------------------------------------------------- ------------ ---------------------------------------------------------------- <br /> , <br /> ------------------------------•--------- ------- ----------•----------------- ----------------------------------• ------------------------------------------------------------------••-- ------------------------------------ <br /> FINAL INSPECTION 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-9-2M Revised W-210D <br />