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r <br /> l � APPLICATION FOR SANITATION PERMIT Permit No.' .._I_�.`�.... <br /> (Complete in Duplicate) <br /> cate) <br /> Date Issued -__./?A3 <br /> Ap cation is hereby made to the San Joaquin Local Health'District'for a permit to construct and install the work.herein described. <br /> �l This application is made in compliance with County Ordinance No. 549x` <br /> JOB ADDRESS AND LOCATION...__ <br /> .....................................---------- <br /> Owner's Name--------- <br /> Address------ <br /> -------Address-------- • _ L.. . '� - <br /> Contractor's Name------------ ------ ._(.. 4. C. Phone--,�_= ! <br /> Installation will serve: Residence j Apartment House ❑ ommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __✓./._._ Number of bedrooms ,,?- Number of baths/... Lot size ...j az:2_ '_ ---­--------------- <br /> Water <br /> •----------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table, ,�!'C'' ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobHardpan ❑ <br /> Previous Application Made: Yes ❑ N?)�( New Construction: Yes ❑ N' \ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sceptic Tank: Distance from nearest well-----------------Distance from foundation---__-...____-___--.Material-------------------------------------- <br /> _----------- <br /> / , o. of compartments--------------------------Size--------------------------------Liquid depth --------. Capacity...-- . --- <br /> LDisZ79�posal Field/�N: Distance from nearest well_____ __________Distance from foundation--------------------Distance to nearest lot line................*474 <br /> Number of lines-----------------------------------Length of each line..............................Width.of french___.... _-____-----------------� <br /> �T Type of filter material-------------------------Depth of filter material___-_--_- - Total length..._ ----_----------------------- <br /> Z_ <br /> -_-..•__ _____-----__ <br /> Seepage Pit: Distance to nearest __--Distance f m fdu dation__.._T..... Distance to nearest lot line <br /> -- <br /> Number of pits---/_______________Lining material ��-z �+__.Size: Diameter.._._ � � Depth -.� <br /> Cesspo I: Distance from nearest well___--------------Distance from foundation---.____ -_---____.Lining material. ___--_--_---.--.. �w_.. ._._. <br /> ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity...................... <br /> ----..gals. <br /> Privy: Distance from nearest well ----__-____•__--__--__.--.-____-_-.-Distance from nearest building------------------------------------------ <br /> Distance <br /> __-_.._-_----__--.-------____.-. _____--- <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 nd rul regula ' ns of the Sen Joaquin Local Health District. <br /> _ / . : <br /> (Signed) ,_� .---- .r ------ -- ------ •- •--------------••- ••---•-------------------• (Owner Contractor) <br /> BY: �-'�- r�a = -------(Title. ----- <br /> -------- --- -- <br /> .� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be ed on reverse side)/ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------•------------------------ ----------------------- - . •-•------------•-----••••-- DATE........... --•- --- ---- - - <br /> REVIEWEDBY------------------------------------------------------------------------------------1 -----•---------------------- DATE.....---------• --- ---- . ----------------- <br /> BUILDING PERMIT ISSUED........................................................................................ ------- DATE----------------------------- <br /> Alterationsand/or recommendations------------------------------------------------ -- ------------------•---------------------•---•--------------------•-•--•-•--------------•------•-•-----•-- <br /> ----------I----------------------------•---------------------------------------------------------------------------------------------------------------------................................................-=......... <br /> ------------------------ ------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------•------ <br /> FINAL INSPECTION BY-------------------------------104 t !" 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 10-52 Revised W-2100 <br />