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. ° <br /> P <br /> Permit No. <br /> APPLICATION FOR SANITATION PERMIT ..,1/. .... ' <br /> (Complete in Duplicate) <br /> Date .tsed � _-- <br /> Application is hereby made to the Sen Joaquin L, at Health District for a permit to it' struct and install the wort:here�rf�leserit?ed, <br /> This application is made in complianct.,with'twrity Ordinance_No. 549. <br /> F, <br /> JOB ADDRESS?AND LOCATION - ----------- .' ' ...... ............ ......:. ... ..... .................. <br /> Owner's Name <br /> Phone <br /> y <br /> .Address <br /> Contractor's Name. /4 ......................................................................................... Phone...._......_............. <br /> -------------------------- <br /> Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court ;❑ Motet ❑ .Other ❑ <br /> Number of living.units: '_.._.-Number of;bedrooms ___ Number of baths Lot size -------­---------------- <br /> Water <br /> . ------- ------- <br /> Water Supply: Public system ❑ Community system ❑ Privete j? Depth to Water Tables f' . ft. <br /> Character of to a depth of 3 feat:° Sand 0... ceut,. }. pdt„L ) Clay Loam❑ Clay(� Adobe❑ Hardpan[] <br /> Previous Ap on YRs Q, ! ' �'” <br /> �. <br /> .m, <br /> TYPE OF INST bN AND SPECIFIC.tATIONS: <br /> (No septic teeth or'cesspcol;pe, n s'd if public sewer is available wifhin 200 feet:) : <br /> Septic Tank: D:i„stance from4nearesf well...S.......Distance from foundation---�` !-._-�. Material <br /> NOq'of x a trrtet,ts... .. Sirs 'I" I :_..Liquid deistl� --.Capac�t�r l� ._.._. <br /> Dis osal l= ld; l7ist4nee lrearast well,. d.----- m fau daton_�©. --.Distance to nea±eat. " line..........--..-.. <br /> F�fumP.° in+ar .. .... Length of each=ine, 1 <br /> - ---- --------Wrdth.:of tie <br /> --------- t <br /> Typ1t o Depth of filter +nateriet._1..11 . _._.._.T�FeI- tang#h.t • <br /> - -•---- <br /> Seepage Pit: Dist4rice to neam- wel .....-Distance from foundation ....... Distance to nee esf lot lug <br /> ❑ Nuxer of pits... # Lining material...._ _Size Diameter ---_-_ Depth -.. <br /> •- <br /> Cess <br /> Cesspool: Distance from ne st well----------------Distance from foundation _....--........Lini material„ <br /> p a --...... ................. <br /> Size: tameter._-- �n-_-- Depth w..-Liquid Capacity gals s. <br /> Privy: Distance frorfi n`'_e�ett well.............................-------­---------- <br /> :. ...........Distance from nearest building,,- <br /> ................... <br /> Distanceto neare of line................-.................................-- .................. ---•-.......-............................. ... ........... <br /> k <br /> Remodeling and/or repairiing descri ) <br /> ------------ ---•=---- '-........................ ',---. <br /> I hereb that I have re aced fhis.a fication and stat the work wig be ......dna in accordance with San J <br /> fY P p pp. <br /> ord�nancet, t laws, and and regulations ori"the San Joaquin Local Health Wisfcic . m <br /> Lou <br /> x . <br /> (Sig ------------------- --- -- --- --------- ..... - ------------------ ----- --- ---- -- ail# <br /> B ...... --------------------------------- <br /> ---- -- g (rifle)p ------ ------------ <br /> - ------:...-•---- <br /> (Plot plan. showing size of loft, Iocatierr of system in relation to wells, buildings, etc., can be laced om verse side <br /> FOR ARI�+ffNT USE bNLY <br /> w <br /> APPLICATION ACCD BY <br /> ....................................................... DATE_> y` <br /> REVIEWED BY- DATE <br /> N. <br /> BUILDING PERMIT'ISSUED,- . DATE: <br /> Alterations and/or MIntendations <br /> --•..... ...............: . • --=•---• .• -•••- •---=--- ......_ ...: .._., . .....,... ..._... ......... _..---=- •....-• ---•--•. <br /> FINAL INSPECTION <br /> BY:.. Date__ :_� ''�I) <br /> SAN JOAIIIN LOCAL HEAfi:TH DTRICT <br /> 130 Sou* Amorkaa Street 300 West oak Streat 132 Syean+ora Sfreet $14 NwA "C'$freat <br /> Stockton, California Lodi, Caftfornia Mama". California Trac C+lifornia <br /> ES-9--4M Revised T.57 VPM. <br />