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t� APPLICATION FOR SANITATION PERMIT Permit No. .... .. ... .... <br /> /o <br /> (Complete in Duplicate) Date Issued _____1--�-/ <br /> n - <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.,�49. J 1 <br /> JOB ADDRESS AND LOCATION _� _. v7 S/ <br /> Owner's Name---�----- <br /> ` � -- ------------------ - --------------- ---------- ----- -----------Phone.----------------------------------- <br /> ----- ----�-- <br /> Contractor's Name__. � - - <br /> - Phone - <br /> Installation will serve: Residence &-Tparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: j--. Number of bedrooms j-_._ Number of baths ----- Lot size --,5--.Q x____. ---------------------- y <br /> Water Supply: Public,.system =unity system ❑ Private ElDepth to Water Table d-0ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe&7ar_ppan ❑ <br /> Previous Application Made: Yes ❑ No w-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 /> iy <br /> 5e is Ta <br /> Distance from nearest well_- Distance from foundation--------------------Material______._____-_. ----- <br /> No. of;compartments-.------------------------Size--------------------------------Liquid depth--------------------------Capacity-----------•----------- <br /> is sal Fi Id: Distance from nearest well-----------------Distance from foundation_._.---------------.Distance to nearest lot line.-_----__---_---- <br /> Number of lines-----------------------------------Length of each line----------- ----- -----------.Width of trench---------------------------------- <br /> Type of filter material......................._Depth of filter material----------------------- length--------_-_--_._:-._-...__.-__-____---_. Ln <br /> Seepage Pit: Distance to nearest welC_ _ om foundation___._ ______.Distance to nearest lot line...t .__---_ 0 <br /> Distance <br /> t/ <br /> ........... . Lining material_ _Size: Diameter__2—f `r ___.De <br /> thZP-------------Number of pits._ <br /> Cesspool: <br /> 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 to nearest lot line- ---------------------------------------------------------------------=--------------•----------------------------------------------------- <br /> 3 <br /> Remodelingand/or repairing {describe}=--------- ------------------------- ----- ----------------•----------•----•------------------------------------------•-----------------------------._..: <br /> ------•---------•--------------•------------°------------------------------....------•------------------------•------•---------.---------------•------------------- ---------------------------------------------------- <br /> ------------ <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,Apte la s, an rules and regulations of the San Joaquin Local Health District. <br /> Si ned ------ --- ----M4--t.----- --------- (Owns- r.�ontractor) <br /> g } <br /> By:---- -------------- --------------------------•--------(Title)---------------------------------------------------------------- <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------—-------------- --------------------------------- <br /> ----- ------ --------------- ---------------- DATE---------- -----•------- <br /> REVIEWED BY----------------- ------ ----- -:--- ---- --- - -- --- - C-'------•-------- -......--------- <br /> ? BUILDING PERMIT ISSUED----------------------------- ----- ------ DATE----------- -N '- <br /> -------------- - -------------- <br /> Alterations <br /> -•----------- <br /> A teri'.ons an r recommendations---- ---------- ------ - - ----------------------------------------------- --- <br /> -----•-------------- •----------•-------- ..._..... <br /> --- <br /> ------------------- <br /> ----- -- - <br /> -- <br /> ----- ---- -------- ------ ----- _ <br /> --------- ---- --------------------- ------------------------ - - <br /> -------------- ---------------------------------- ------------------ ------------ ------- ----------------------- <br /> FINALINSPECTION BY:. ------------------------------------ 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 /> E8__9-2M 145445 ATWOOD 12-54 <br />