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APPLICATION FOR SANITATION PERMIT Permit No. ..i�!_r�:z' <br /> Z I O (Complete in Duplicate) s�Y <br /> Date Issued ._ ................ <br /> Applica+ion 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 0 dinancA No. 54,9. <br /> JOB ADDRESS ANA LOCATION-•-- .. ---f-------- --------- ------------------•---------------•-----------•---------------------•----- <br /> Owner's Name. ---- ....... ...........--- •----•----- ----------••-----•-----•••--•---- -------------- _ Phone <br /> Address._....1.. .... --•--•----- -----------..............-------- --.... <br /> Contractor's Name- -- ----• -•---- -•-. -• r.Q Phone 2 14 <br /> Installation will serve: Residence 9�_4artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: �0'.__ Number of bedrooms _ _. Number of baths .t`'---- Lot size ......................... <br /> Water Supply: Public system 6-community system ❑ Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam❑ Clay ❑ Adobe[ "Aar an 0 <br /> Previous Application Made: Yes ❑ No { -Wew 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 nk- Distance from nearest well_-:--------------Distance from foundation .._..._.__.._..Material----------------------------------------------- <br /> r / No. of compartments------ - Size---------------------------------Liquid depth------------- --...-Capacity---------- ------Y .- <br /> isposal Field- Distance from nearest well-----------------Distance from foundation....................Distance to nearest lot line................. <br /> p Number of lines-----------------------------------Length of each line-------------------------------Width of trench................................... <br /> / Type of filter material--------------------- Depth of filter material----------------------- length.......................................... <br /> r <br /> Seepage Pit: Distance to nearest well,,v ____1D1_1stance foun ation_..:A/4:7 /...Distance to nearest lot line ..__.. <br /> Number of pits-------/----- - Lining material__- _,Size: Diameter-k3 `----------Depth__2p-.-' ----•-----•- <br /> Cesspool: Distance from nearest well----------------- from foundation___-----------------Lining material..........-------------------------- <br /> El 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, S laws and s and regulations f the San Joaquin Local Health District. <br /> (Signed) ------------ --- ----- ei.andfvI -Wntractor) <br /> By:------ ---- -- -`,^-------------------------------------- -•------- (Title)--- ---- --- ...... .------------------------------------------ <br /> (Plot <br /> -------------- -------------- <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 /> REVIEWED BY---------------------------------------------- - ---- DATE ................................. <br /> BUILDING PERMIT ISSUED---------------------------- ------ - --------------•------•--•-• ... DATE ------ s <br /> "11 <br /> Alterations and/or recommendations:-------- --------- V -----------------.•-------- •---=--------•---- - ----...... <br /> --------•------.....-•-----•-----••----•--•---•--------•--------------------------•-----------------•---------•---...-----••----- --------•--..............................--••----................................ <br /> - <br /> --------------------------------------------------------------------- ------------------------------------------------------------ --•---------- - -----_ --------------------- <br /> FINAL INSPECTION BY:/ � ............. Date.....l-1------�d �`�� <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 /> E5-9-2M 145446 ATWOOD 12-54 <br />