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f <br /> a\� <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> /��] � (Complete in Duplicate) ([I <br /> 'l i/10 Date Issued -_!--_� ks .­ <br /> g <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> s application is made in compliance with County Ordinanc o. 549. <br /> JOS ADDRESS AND LOCATION __ ------1194- R <br /> r <br /> Owner's Name----------- - - ----- ---- --- - ------ --- - ------------------ one <br /> Address_ = --- - - ------- ----- <br /> Contractor's Name___ ___ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mo 1 ❑ Other ❑ <br /> Number of living units: _ _____ -ber of bedrooms , Number of baths /___ Lot size ____:_ -------- ---'l S-_OK <br /> Water Supply: Public system 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 Hardpan Ll <br /> Previous Appiication Made: Yes ❑ 140 Gravel <br /> Construction: Yes �lo El . <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> t <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation---- Material________-____________-_-_________________-___. <br /> } No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity--•-------------------- <br /> Disposa Field: Distance from nearest well-----------------Distance from foundation-----------------._.Distance to nearest lot line___________-._._- <br /> Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- <br /> Type of filter material__ epth of filter material-----------------------Total length------------------------------------------- <br /> Seepage P .' Distance to nearest wel__ ______ <br /> Distance f fpu )tion_-__ _ <br /> ,� -_-_Distance to nearest lot line-10 <br /> Number of pits__' ______Lining rnaterial_�7k� c.Size: Diameter__X---------------Depth__��----________-_ <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 /> ------------------------------------ <br /> Distance <br /> -------------------•--------------_ ---Distance to nearest lot line------ ---------------•---- ------ -- <br /> - ----------------------------------------- <br /> Remodeling and/or repairing (describe):__-__-_ - _-----___ P� <br /> ------------------------------------------------------------------------------------------------------:----------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------- ----------------------------------------------------------------------------------------------------•-----------------------------•-------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa4iiin County <br /> ordinances, Stat laws, and rules an regulations of the San Joaq 'n Local Health District. <br /> (Signed)------f-'---- d>- <br /> e� <br /> ' ---_(O er an r$Y= - �-� --• ----------------- --------------------(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 /> ----------------------------- <br /> REVIEWED BY - - -� DATE----- <br /> BUILDING PERMIT ISSUED ---- -- ----------------------------------------- <br /> ---------------------------------------- DATE-----------jU� <br /> Alterations and/or recommendations:----'---------------- --------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------•------------. <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:-------------- <br /> --------------------------- -------------------------------------------- <br /> SAN <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Proof 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES—v-2M a-51 Revised W-2100 <br />