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ry n APPLICATION FOR SANITATION PERMIT Permit <br /> '"n, r (Complete in Duplicate) <br /> Data Issued --t_f��� <br /> egp�l <br /> lation is hereby made to the San Joaquin Local Health Distr�Cff,forRti�permit to construct and install the work herein described. <br /> s application is made incompliance with•County Ordinance No. 549. 1 , <br /> JOB ADDRESS AND+ LOCATION -------vy-�----------is----------- gyp -----------------------------:-------------= <br /> I <br /> Owner's Name----- ---------- ------ ` ----------�-------------"' '=----------It-----------------------------------•--- Phone-------------------- --------- <br /> Address...... <br /> --------Address.-•---`----------•- -•--••- ----- <br /> --------------------------------------------- <br /> Contractor's Name--------------------------------- -------- Phone----------------------------------- <br /> Installation will servei 4 Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ ,Other ❑ <br /> Number of living units: ___ Number of bedrooms _A___ Number of baths ----1--- Lot size ________ ------.f _Z__________________ <br /> Water Supply: Public system OR Community system [I Private E] 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 ❑ New Construction: 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 _-Distance from;f <br /> - dation_____yd_ ._____.Material___-----_-- -�------�-_---------------- <br /> ts_ __.._.__ _ p �`�.--____-_Capacity._.__Yv _No. of compartmens - L <br /> �w <br /> jg <br /> Disposal Field: Distance from nearest well-------k"-- Distance frem,fcuntlation----2b-------.1Distance to nearest lot line----- s <br /> Number of lines______________ ___ Length of each line___Lo'---Y-S-_.�f.� -?DW11dth of trench_i------1Y_1..______.._______. <br /> Type of filter material-------__)l `7-h ep-h of filter materi�190"1'�'_— .Total-.Total length_-_____V�l________________________ � <br /> a <br /> Seepage Pit: Distance to nearest well____________________ ista�rom found`ation________________._.Distance to nearest lot line----- •Isk1 <br /> ❑ Number of pits----------------------Lining mater l-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well_______________----�Qe Distancethe- -��-- -foundation-----.--------___--.Lining material-------------------------------------- <br /> ❑ Sizer Diameter----------------- ------ - --- -------------------Liquid Capacity •------------- ---------gals. <br /> _FFr m <br /> Privy: Distance from nearest well----------_------i._____._____________.__._Distance from nearest bund:ng--------------------------------:........ <br /> . <br /> ❑ Distance fo nearest lot line------.__------- �- <br /> Remodeling and/or repairing (describe)------------------------------------------------------- --- --------------------- <br /> ----------------------------------------- ------------------------------------------------------�t-\wj.......--)M-V\------------------ ---------------------------•---•---•------------------------------ <br /> i <br /> -------­-­------------- <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, Sta a laws, and rules and regula ions of the San Joaquin Local Health District: <br /> F - <br /> (Signed) --- �-- -- ions., <br /> ----------------------------------------------------------------i--------------------(Owner and/or Contractor) <br /> By------------------------I---....---------------------------•------------------------------------------------------------------------(Title)--------------------------------------------------------:----- <br /> a <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildingsr etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------------------------------- - --� DA ---------3 <br /> _-- _ , <br /> REVIEWED BY <br /> -- ------------------------------ -----� -------_------------------------------- DA ------------- <br /> 1 ---------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------- ---•-- --•--------•--•-------------------- <br /> Alterationsand/or recommendations:------------------------------------------------- --..--------------------------------•---------••----•----------------------------------------•--•--------_.. <br /> ------------------------------------------ -•••------- ----------------------------------------------------------•--•--•---------------------------•-------------------------•--•--•---•------------------------------- <br /> -----------------------------------=-------------------- -----------•- ----------------------------------------•-----•-------------• -•---------------------------------•----------------------------------------..------- <br /> Vley ?(- '�/I Date- VAFINAL __INSPECTION BY:-------- ----- I --------------------------------------- <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-4-2M 10-52 Revised W-2100..,, <br />