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APPLICATION FOR SANITATION PERMIT P `ut i No. <br /> -- <br /> •• <br /> t �• (Complete in 'Duplicate) -,i <br /> �'"Z 1 O Date Issued ___.__ <br /> Applica4ion 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 Coou++nty Ordinance N 549. <br /> JOBADDRESS AND LOCATIO _3_..3---/_-----------9®---- ------ ----------------------------------•------•-------------------------------- <br /> Owner's Name---- ------- -------------------------------------- ------------------------------------------ Phone...................---------------- <br /> Address .............. ------ --- ------ <br /> --- -------- ----____•--------------- <br /> _ / <br /> Contractor's Name____ _ __-________._. Phone _ !7Z64_�__ <br /> Installation will serve: Residence 0 AP rtment House ❑ Commercial ❑ Trailer Court ❑ Motel Q, Other El <br /> Number of living units: j___ Number of bedrooms Number of baths __/___ Lot size .....Yv_____, .__ ._d.................. <br /> Water Supply: Public system h �o-a nunit�r system ❑ Private ❑ Depth to Water Table &TR 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 r(L _. <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sept' Tan k• Distance from nearest well-----------------Distance from foundation....................Material-------------------------------------............ <br /> '' No. of compartments_-----------------------Size.............................---Liquid depth--------------------------Capacity----------------------- <br /> ispo I 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----------------------- length__________________________________________ <br /> Seepage Pit: Distance to nearest well/ ---Distance omfou ion----1 e to nearest ine <br /> Number of pits--------�------------Lining mater' .__ Si Diamet r_ 3--, _.____Dept _______ <br /> Cesspool: Distance from nearest well-____-___--.____Dis ndation---------.----------Lining material------------------------ "4 <br /> ❑ Size: Diameter----------------------------- -------Depth-------------------------------- -------------------Liquid Capacity............................ <br /> Privy: Distance from nearest well-------------------------------- from nearest building-----------------......................... vJ <br /> ❑ Distance to nearest lot line-----------------------------------------------------------------•-----•---•---•------•----------_•--•---•--•----••----•---------•------- <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, State laws and�andulations of the San Joaquin Local Health District. <br /> (Signed). - - - -•-- ------ ---------- ------------------------------------------------------------- (Owner end/or Contractor) <br /> OOP <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......... <br /> BY----------------_--- ------- -------------------------------------------------------------------- DATE------------- ---.-.-�- -/---------------------------------- <br /> BUILDING PERMIT ISSUED------------- ----- --------- -----•---------------------------------------- ......... DATE__..----------------_•fit - <br /> Alterations and/or recommendations--------------------- ----�----------....--•--------------------------•-------------------•---•-------•--•--•-••-_------\IJP/ <br /> ----- -------------- -------------------------------------------•----------------------------------- <br /> - - -------- <br /> ---- --- .... <br /> - .._._ _... ------ ------------------------------------------------------------------------ <br /> ------------------------------------ ------ --------------- --- ................................ ---- ------------------------------ ................................................................. <br /> ( <br /> FINAL INSPECTION BY__________ _ ___ _ Date.......-.Y/ ----- <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 145446 ATWOOO 12-54 <br />