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._91 <br /> +IVIq <br /> APPLICATION FOR SANITATION PERMIT Permit No. .. ......... .. <br /> (Complete in Duplicate) -- <br /> Date Issued <br /> Applica}ion is hereby made to the San Joaquin Local Health District for a permit td construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. ` <br /> JOB ADDRESS AND <br /> LOCATION <br /> TION ..r.••7 ` t— _ q/- -- Y � - <br /> ------- ---------------3�----- <br /> Owner's Name_ ------ •-------—-------------- ........... Phone-------------------------- <br /> ---------- <br /> Address... <br /> -------------------------Address----•---------------------=--------------------'-- <br /> Contractor's Name----------•-_------------- ----- -------------•---------------------------------------------------------------------- •- ------ Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other <br /> Number of living units: _./__. Number of bedrooms 1----- Number of baths __/__ Lot size - _77.�_- -- -Q_' - -----•-_,-__-_ <br /> Water Supply: Public system ❑ Community system ❑ Private 0--Depth to Water Table ft. � <br /> Charac4er of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam E] Clay E] Adoba E] Hardpan E] <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 T i Distance from nearest well.. r��.------Distant efro joun�a ion_c�Q.�-----_Materia)._`�_ _. <br /> -__- <br /> No. of compartments...s„�..�...------t--.--Size_, �- -,�e�..---Liquid depth-------�4--------------Capacity_ <br /> -����-- <br /> Disposal Id: Distance from nearest well__.______Distance from foundation.3�._--------Distance to nearest lot line <br /> Number of lines......... . ... ....... Length of each Iine._..... ..�._ Width of trench..... . `___ <br /> TypeT e of filter material__ <br /> ,. - Depth of filter material-----/-_.__....Total length--------- L ---------------------- <br /> Seepage Pit: Distance to nearest well., -------------------Distance from foundation--------------------Distance to nearest lot line---_-.-------..._ <br /> ❑ Number of pits----------------------Lining material------------------------Size: Diameter-----------------------Dept h--.........---------_------------ <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 to nearest lot line-------- ------ -------- ------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)---------- ------- ----------------------------------------------------------- ------------------•-------•----------------------------•------------------- <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 /> (Signed) (Owner and/or Contractor) <br /> By: A_­#..�... � Title -----y. .......---•------------- ----------------------------------------------- ---------- --------- ----( ) <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTM NT USE ONLY <br /> APPLICATION ACCEPTED BY-- r - ----- DATE------ <br /> REVIEWEDBY----- ---------- ---------------------------------------------------------------------------------------------------------- DATE------------------------ <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------- ------ ------------------------------------- DATE--------- <br /> Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------_-------------------- ......... <br /> - <br /> •-------------------------------------------------------------------------- - --------------------------------------------------------------------------------------------------------------------•----------------_-------- <br /> ------------------------------------------------•-------- ---------------------------------------------------------------------------------------------------------------•-•---------•--------------------------------------- <br /> ------------------------------------------- --- - - -- --- -------------------------------------------------------- --------------- -------------------------------------------- ----------------------• -------- <br /> FINAL INSPECTION 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 />��ES—�9--2M igsgg5 p'rW[]�P 12-54 <br />