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�T <br /> °� APPLICATION FOR SANITATION PERMIT Permit No. . /...... <br /> s- <br /> (Complete in Duplicate) ly <br /> � Date Issued <br /> Application 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. 5 <br /> JOB ADDRESS AND LOCATION—.4 <br /> ----------------- ----- - -- ---------•-• -__- --- ------------------------------------- <br /> .Owner's Name...... - - • ••-• Phone <br /> - ----- --- ..... <br /> Address......S ' . •-•-•• • ----- --••--• �� ------------ <br /> •------ r ^° •_ <br /> Contractor's Name---- .......%� Phone `•7 I� 1(. <br /> Installation will serve: Residence Ap8rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑' -Other ❑ <br /> Number of living units: ...I... Number of bedrooms ..--Number of baths ._1... Lot size -4Q_--!(_.L._�......-_..•.........•_--------- <br /> Water Supply: Public system 0.-<O—Mmunity system ❑ Private ❑ Depth to Water Table ff!� ft. ' <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan-❑ <br /> Previous Application Made: Yes ❑ No [""New Construction: Yes ❑ No [1-a <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer..is.available within 200 feet.) <br /> 4D'isposp,i'l <br /> pti - ank• Distance from nearest well-----------------Distance from foundation....................Material <br /> No. of compartments----- ---- ---- Size_-_--•-•_ __-__--___-_-_.___Liquid depth-_-:. .----. ------_____.Capacity ..--••. _.._Field: 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-----------------------Total length..... ......... _. <br /> Seepage Pit: Distance to nearest welk'27 --t-- Distance from foundation----4.0-._... •stanc t nearest lot hne 2-- <br /> �.-- Number of pits----1 ------- ----Lining material_eZA' ._.Size: Diameter... epth-------1 P4............... <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 Fine---------------------------............................................---------------------------------• .---- -------- ---•---- <br /> Remodeling and/or repairing (describe):... (- - - <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, St a Is, an rules a d regulafloys of the San Joaquin Local Health District. <br /> (Signed)..-- --••••• ••• -•••----- •. • --•• r Contractor) <br /> • <br /> A <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 -y <br /> REVIEWED BY-------------------------------- ---- ------------------- --------------------------------------------------------------- DATE -•--•••--67- - <br /> _�(.- ---•-•. --------- <br /> BUILDING PERMIT ISSUED----------------------------------------- ----•-----•-•-•-•---..................... -------- DATE........................ ---­---_-------_----------­." <br /> Alterations <br /> -- ---•---- --- <br /> Alterations and/or recommendations: - --------------------------------------------------------------......................................................................... <br /> ---------------------------------• ---------..........................-...................................-•--•---------------........................................................................................... <br /> ...__...-• -•----------•--- - ---------------- ......-- . •••••- <br /> _ <br /> FINAL INSPECTION BYDate------ ----------- -------- ------ ------ -------------•---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M 145446 ATWOOD 12-54 <br />