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APPLICATION FOR SANITATION PERMIT Permit No. ------4.l>___7s?_./_ <br /> (Complete in Duplicate) <br /> ��/ Date Issued _____:_/'e 3/1� <br /> Application 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 Ordinance No. 549. <br /> JOB ADDRESS AND LOCATIO __8'a _ s '___ �------- <br /> ____--------------------------------------------------- <br /> Owner's Name.... ` � _., _. . --------------------------------------------------------------------------------------------- Phone------------------------------------ <br /> Address------_--. a ---------:t ---------------------------------------------------------------------------------------------------•------------------------------------- <br /> Contractor's Name------- __`,n- --rn-- v_ ------------------------------------------------------------ ------ Phone----------------------------------- <br /> Installation will serve: Residence 131--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> . 1 l �' <br /> Number of living units: .-_ Number of bedrooms Number of baths -__/-_ Lot size _, a ___ -----------_______________ <br /> r <br /> Water Supply: Public system Urcommunity system ❑ Private ❑ Depth to Water Table .0- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe lardpan ❑ <br /> vious Application Made: Yes ❑ No New Construction: Yes ❑ No [RI FHA/VA: Yes ❑ No [+ <br /> PE 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 /> No. of compartments---------------------- ---Size----------------------------=---Liquid depth--•-----------------------Capacity----------------------- <br /> ispo 1 Field: Distance from nearest well-"_______________Distance from foundation--------------------Distance to nearest lot line................. <br /> yPNumber of lines___________________________________Length of each line------------------------------Width of trench_______________________________:___ <br /> / Type of filter material-------------------------Depth of filter material-----------------------Total length.---------------------------______________ <br /> Seepage Pit: Distance to nearest well__ _'_Distance f om f dation__-��_._.....Distance to nearest to Ii e___/ __�_ <br /> ®� Number of pits,___,/`_____________Lining material-__#+4 .Size: Diameter__ ��______Depth_-.-a ------------------ p <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 /> ❑ Distance to nearest lot line------------------------------- --------------•-------------------••-------------------------------------------------------- <br /> Remodeling and repairing (describe): ��`F <br /> A ------- <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 lawaanules and regula ions of the Sart..Joaquin Local Health District. <br /> (Signed)-------------------- `' -- ---- '�- '" --------------------- --(�F-Contractor) <br /> By--------------------------------------------- --------- ' -- ----------------(Title)-----1 -4" ---------------------------- <br /> ------------------------ <br /> (Plot plan, showing size of lot, locat' of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY------------- ------------------------------------------- ---------------------------------------- DATE------------------------------------------------------- <br /> REVIEWEDBY------------------------------------------ ---------------------------------------------------------------- ------ DATE_-----_---------- <br /> BUILDING PERMIT ISSUED------------ DATE..-- ------ <br /> - -Alterations and/or recommendatiofins: --- - ---- ------------------------------------------------------------------------- -- ------------------------------------- <br /> ----------- ----------- ----- ----------------------- ----------------------------- -------------------- -------- ---------- ----- - ----------------------- <br /> ------ ----------------- ------------------- -- ----- --------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------- <br /> ------------- ----- ------- ----- -- - - ---------- <br /> ------ <br /> --------------------- <br /> FINAL INSPECTION BY:-------t 1 - Date �a <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 Revised 1.57 F.P.CO. <br />