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41 �) APPLICATION FOR SANITATION PERMIT Permit No. .....�..gf, <br /> I e (Complete in Duplicate) <br /> . Date Issued .... <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 Coupnty Ordinance No. 549.. <br /> JOB ADDRESS AND LOCATION--------- <br /> Owner's Name----------------------- --------------Wm4,.__A-d_(7m- _S------------•-- ---------------------------------------.-- Phone-c"'- _409 ----- <br /> Address �A?J?E? <br /> s ty°r ta. <br /> - -r ------------------------------------------- PhoneQ- 46-o.7._------ <br /> ---------------------------------------------------------------------------------------------------------------------- <br /> Contractor's Name................................. <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ <br /> Number of living units: _1____ Number of bedrooms A_. Number of baths .1____ Lot size .._. �� �_.�..� '- <br /> Water Supply: Public system ElCommunity system E] Private X Depth to Water Tab <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Df Hardpan ❑ <br /> Previous Application Made: Yes ❑ No Y New Construction: Yes ❑ No ❑� Pms'/1J�'9�"�l Q�/'Aii���E� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic%TarDistance from nearest well-----------------Distance from foundation--------------------Material---------------------------------------.--------- <br /> WJ � No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well------------------Distance from foundation....................Distance to nearest lot line-_-_._------..__- <br /> Ei&nC, Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- 00 <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length---------------.--__-----_-•._.._-__----_ <br /> Seepage Pit: Distance to nearest well-M-0------------Distance from fppundation__IA.•-..........Distance to nearest lot line._/p._-.... <br /> Number of pits__-------------------Lining material_ 11Ck....Size: Diameter--- y Depth---.�.� U/ <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------.-----------------------------------7 <br /> ❑ Distance to nearest lot line r, <br /> RemodeIng.epd/or repairing (describe)------- ------- -------------- - -------•--------------------•------•-----------•--- • -- _---••------------------------------------------- <br /> --•••-----•-•--•--•--•-----------•-•--------------••-----------------------------•----------------------------•-----•-•--•------------------•------------•------------------------------------------------------------------ <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 law ules and regulations of the San Joaquin Local Health District. <br /> AR !S c� <br /> (Signed)-•--------_- •-------------------------------C& ----------- --- ( r Contractor) <br /> BY: --------------------(Title)--- --- ------ <br /> ---------------------------------------- <br /> (Plot plan, showing size of lot, location of system in rel ion to wells, bu dings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- -- ------------------- -- - '- ---«i---- - ----------------------- DATE----- <br /> �--------------------------------------------------- <br /> REVIEWEDBY------------------------------------------ ----------- ------------- --------- DATE------------------------------- <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------- ------ DATE--------------------------------------•--------------------- <br /> Alterationsand/or recommendations:.................................................................................................................................................. <br /> ----------------------------------------------f•... <br /> ---------------------------------------------------------- ------------------- ---------------------------------------------------------•---------------------------------------------- ------------------------------------ <br /> -----------------•-•------•--•-------------------------------- <br /> x <br /> FINAL INSP N BY------------- ............. ------ ---------------- - Date---------- 1` <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 10-52 Revised W-2100 <br />