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APPLICATION FOR SANITATION PERMIT Permifi <br /> \1'�11 (Complete in Duplicate) <br /> Date Issued'.S� +5' <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 iii compliance with County Ordinance No. 549. <br /> r f1 <br /> JOB ADDRESS AND'LOCATION-----�.; _ ------- . G� •... - i <br /> Owner's Name----------------------f�---------fl4_1 Ya 1'-. ----_------------- }hone <br /> Address----------•------------- -------------- -------------------------------------------------------------------•----•-----•---------------------------------•---- ---------------------------- <br /> Contractor's Name----------------------------------------'-5--0-`_L= �---------------------------------------------------- ---------------------------- Phone----•-•---------------------------- i <br /> Installation will serve:, Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> ea 46 <br /> Number of living units: -------- Number of bedrooms4--_- Number of baths -------- Lot size ____ _ __ ____.-.____________________ k <br /> Water Supply: Public,systemv 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 ❑ <br /> Previous Application Made: Yes ❑ No/ ,New Constriction: 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 Tank: Distance from nearest well__1[/0-------Distance from foundation....jP____----- al-------- --G-----------_-----. , 1 I <br /> p Size ` Ma ,. Ca aci G26 i" <br /> No. of compartments ---- , �•-- --Liquid depth-------_ _--/ P ty... �f <br /> Disposal Field: Distance from nearest well-_-_f0-----__Distance from foundation-----�-------.Distance to nearest lot line---A- ---.--. r <br /> 1 <br /> Number of lines----------- --------------- Length of each line--------2d_----------------Width of trench----------- ------------- <br /> Type of filter material----- <br /> }!y'/------- Depth of filter material----- ---------Total length___.______ -------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation...----------------.Distance to nearest lot line----------------- <br /> Number <br /> ---.._-----___-Number of pits---------------- -----Lining material-----------------------Size: Diameter-----------------------Depth----ppv _--..------------- S F <br /> Cesspool: Distance from nearest we l ----._-Distance ofn foundation_____ .-___Lining material___.__! 1 _.______ <br /> Size: Diameter -----------------DP $_ ----------Liquad�CapacitY = - ���= 9$la> <br /> Privy: Distance from nearest well------------------------------_---.-------------Distance from nearest building----------------------------------------- <br /> ❑ Distance to nearest iot line ------------------------„- -j-----.. ---------------------- <br /> Rerrjodelkg and or re airin describe - --- ---------- ----------------- ------i-=-------.-- ."' <br /> ----------- f------- -,”, h -----•----------------- = - ---------------------- <br /> ----------------------------------- <br /> � I <br /> ---------------------------------------------------------------------------------------- <br /> ------- --------r---------------------------------------------------------------------------•----------------------------------------------------------------------------------------------- - <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, 9nd rules and regulations of the San Joaquin Local Health District. <br /> -V ------------------------ ---- ------------------------------ ----------------------------(Owner and/or Contractor] <br /> (Signed)-.-- ?1:. <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). r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY---------------------------------------- E, ------------------------------•-•------------- DATE------------- .r ----------- <br /> REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE------------------- ----------------------........... <br /> BUILDINGPERMIT ISSUED------------------------------------ ----------------------•----------- ------ DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations--------------------------------------- ------------ ----------------•-•------------------•-------------------------------------------------------------------- <br /> ----------=•---------­­-------------------------------- •------•-------• --------------------------------------------- --------------- ------•----------------------------------------------------------------------- <br /> ----------------- <br /> --------------------------------------- <br /> -------•--•--------------------------- ---------------•--------------•----------------------------------------------------------------------•----•-•-------------•-----------------•----------------------------------------- <br /> - ---------•-------------- <br /> �e_ <br /> FINAL INSPECTION BY:--------- 1A Date-------------------------- <br /> SAN <br /> 7 ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ R <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 /> FS....-9_?M ; IRevised W-2100 <br />