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APPLICATION FOR SANITATION PERMIT Permit No. ................ .. <br /> Z (Complete in Duplicate) Date Issued <br /> Irl SP lica-1-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> T application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AIN�CATION.. �C-917A-�,,,-—---------------------- <br /> Owner's Name----- I - ­0.- ------ - Phone----------------------------------------------------------------- <br /> Address.---- -- ---- ----- ---------=--------`----------------------------------------------- - <br /> Contractor's Name-------------- ------ <br /> i e ; --- - ----------------------- ---------------------------------- <br /> Installation will serve:. Residence,*g,,,Apartment House ❑ -Commercial [-] Trailer Court [-] Motel Ej Other 0 <br /> Number of living units: -- ----- Number of bedrooms-4L. Number of baths --/-- Lot size ­---!;7;fP--,y",-/- --,��-------------------- <br /> Water Supply: Public sysfemA Community system El Private 0 Depth to Wafer Table-z1 ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam El Clay Loam 0 Clay'b Adobe Hardpan F] <br /> Previous Application Made: Yes Ej. NoX New Construction: Ye. ' No [:1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septics T k: Distance from nearest well_________________Distance from foundation--.----------------Material--------- _.____________.___________.__________- <br /> • No. of compartments--------------------------Size-------------------------------- Liquid"depth--------------------------FCapacify------------------; <br /> )ZI Figild: Distance from nearest well....- <br /> -Distance from foundation___- --g0--1----Distanc6.'to nearest'lot line.......------------ <br /> Number of lines___.__'_________________ th c <br /> __-_---Length of each line---------7�­ of fren -- ----- - ------- <br /> -)I--/P- --------Total 'length -------- <br /> Distance to nearest well---------------------Distance from foundation-_..__' Distance to ITT <br /> Seepage- Pit: Type of filter material ---Depth of filter mafer*c foundation____________..:.___.Distance - - --------------- <br /> El Number of its Lining material_________________------Size: Diameter-------------- ---------Depth--------------------- ------- - <br /> Cesspool: Distance from nearest well-----------------Distance from foundation.-----------­­----Lining-mat6rial------------I-------------------------- <br /> 0 Size: Diameter------------------ -------------------Depth------ --------------------------I-------------------Liquid Capacity----------- -------------gals. <br /> Privy: Distance from nearest well-,.----------------------------------------------Distance from nearest building____- -------------------------------- <br /> ElDistance to nearest lot line------ ----------------------------------------------------------- ---------- - ----------- --------------------- <br /> 4f <br /> emo eling andror r airing describe):­ -------- ------ - ----- ........ -------- -- -- -------- ----- <br /> - ------- ----------- --------------------------- -----------------:------------------------------------------------------------------ <br /> -------------------­------------------ ----- --------------------------------------------------------------------------- -- <br /> ----- ---------- ----------------------------------------------------------------------------- <br /> ­--------------------------------- ----------------------- ------------------------------------------------------------------- --------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Safi Joaquin County <br /> ordinances, State ws, and rules nd regul of the San Joaquin Local Health District. <br /> (Signed)--------- ­4r,-- - --- - ----------------- ------------------------------------I.-!-------------- ------------"Owner 44nd <br /> or Contractor) <br /> ----------------------------(Title)- <br /> By:----- ------------------------------------------------------------------ <br /> 00 <br /> (Plot plan, showing size of lot,'locaflon of system in relation to wells, buildings, etc., can be pl&c*a on reverse side <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- ------ ---- -------------------------------------------------- DATE----- ------- <br /> REVIEWED 'BY <br /> -------------------------------------------------------- DATE--------------- ---------------------------------------- <br /> BUILDING PERMIT ISSUED---------------------------­ ------------------- ---------- DATE-------------------------------------------------- <br /> --------------------------------- <br /> Alterationsand/or recommendations:-------------------------- ------- --------------- ------------------------------------ ---------------------------------------------------------------------- <br /> ---------------------------------------- ------------------ --- --- ---—--------- .................. <br /> --------------- <br /> --------------------------------------- -------- <br /> ------------------------------------------ ry-------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------­1- <br /> ---------------------------------------------------------------- .­-- ---- ----------- ---------------------------;-------------------------------------------------------------------------------- <br /> -------------------------- <br /> FINAL INSPECTION BY________________________ Date. .------- ---------- <br /> ----- --------- ------------------- -------------- <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 /> E5I-9-2M Revised W-2100 <br />