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APPLICATION FOR SANITATION PERMIT Permit No. ..... <br /> � -�- <br /> N� (Complete in Duplicate) Date Issued <br /> install the work herein described. <br /> Applica{ion is hereby made to the San Joaquin Local Health District fora .permit to construct and <br /> This application is made in compliance with County O��, <br /> JOB ADDRESS AND CATkON.--•----�- --------•-X/& ------------------------------------------------------------ <br /> --------- - --- ------------------------------------- <br /> Phone---------------------------•---------- <br /> Phone----------------------••-------- <br /> Owner's Name--------------- ---- --- -•--- - -- ........... - - - -- - � <br /> --•----------- - ----- ---------- <br /> / ---•--- - ------------------------------------------------------------- <br /> I <br /> ------------ -------- <br /> Address---�'-r--rro-•=1•`-�•.----�,.A.rX!�C�. �----• ------ ---------..� - ----------------...-----••---------- <br /> Name - ---------------- ------------------------------------------------ <br /> Contractor'sPhone <br /> - - --------------•-- <br /> Installation will serve: Residence ET---Apartment House ❑ Commercial ❑ Trailer Court ❑ Mo#el ❑/ ? -, ❑ <br /> Number of living units: __ -- �Number of bedrooms _ _ Number of baths -_/__ Lot size ._ �____ �•• ------------------------- <br /> Water Supply: Public system ®1Community system ❑ Private ❑ Depth to Watee 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 well-----------------Distance from foundation---------------------Material <br /> ____.________:__-________._._._____.________.-... <br /> ❑ No. of compartmen-ts - Size__..... ......--Liquid depth----------:------- ------Capacity----------------------- <br /> is osal Field: Distance from nearest well_____________ ____Distance from foundation----------.._`__.-.Distance to nearest lot line____.__.-______-- <br /> D p <br /> ❑� Number of lines-----------------------------------Length of each line-----------------------------.Width of trench--------------------- ------------- <br /> Type of filter material------------------ -- -- epth of filter material-----------------_-----Total length------------------------------------------- <br /> nearest Pit: Distance to nearest/well_,/�_ - -- -Distance, fo dation__._?.p_.---Distance to nearestlotline_. 's-/ <br /> Number of pits----l---------------Lining material--- C -Size. Diameter___s �------ ----Depth---oZS_------------------- <br /> Cesspool Distance from nearest well--------------_Distance from foundation_____----::__._____.Lining material___-______---. <br /> -- Li Liquid capacity ---- gals. <br /> ❑ Size: Diameter------------------------------ -------Depth------ '------- <br /> Privy-. C� <br /> Distance from nearest well-------------------------------------------------Distance from nearest building------------------------.--------------- <br /> ❑ Distance to nearest lot line:.----------------- -------------------------••-------------------- <br /> Remodeling and/or repairing (describe):--------- --------------------------- ------------•------•---------- ----------------..-----•---------•----------------•-----------------------------•- <br /> t ____________________________________________________________________________________________________________________________Y___-.-------_------------------------------------------------------------------------------------ <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 regulations of the San Joaquin Local Health District. <br /> Owner and/or Contractor) <br /> (Signed)---•--- •-------------•--------------------- 1,/ <br /> / <br /> --------------{Title) ----------------------------------- <br /> BY: <br /> (Plot plan, showing size of lot, location of system in relation t wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION.ACCEPTED BY--------------------- -------------------------------------- DATE <br /> ------------, .,------------------------------------------------------------ <br /> --- - -- - --------------- <br /> REVIEWEDBY-------------- ------------------------------ -- ------ ------------------------------------------------ DATE <br /> - DATE--------- --- ---- 14----------------------------------- <br /> BUILDING PERMIT ISSUED-------------------------- - <br /> Alterations and/or recommendations------------- -------------- ------------ <br /> ---------- __ -v---------•----------•-------- <br /> -------------- ------4- _t k_ _- ............ . ........ -- -------------- <br /> -----------------­----- <br /> --------------------------- <br /> ------ -------- ----- --------------••----_------------------ <br /> ..............-•------------------------- - --------- <br /> e ! -------------------------- <br /> Date_. <br /> FINAL INSPECTION BY:_____--- -- ----------=-- <br /> .v- � --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street in Sycamore Street 814 North "C" Street <br /> Stockton, California <br /> Lodi, California Manteca, California Tracy, California <br /> ES__9 145446 ATWOOD <br />