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it No' __,ra!_7 <br /> APPLICATION FOR SANITATION PERMIT Per"m _____ <br /> (Complete in Duplicate) <br /> �y Q 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 applicatigp 6 made in compliance with.County Ordin nce No. 549. <br /> JOB ADDRES i AN CAT N__________ _ <br /> Owner's Name-- -- - --- ---- �---------- ------------------ ------ Phon ,/... <br /> Address t- <br /> _ ---_U?' <br /> Contractor's Narrip----- --------- ---- - -Al --------------------------------------------- Phone_ <br /> Installation will ser Residences Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of;i rg units: ___/__ Number of bedrooms _,-?--- Number of baths ___/__ Lot size ____, --_____________________ <br /> Water Supply: Pubi c �system11K Community system ❑ Private ❑ Depth to Water Table 4�ft. <br /> Character of soil to 4deypth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob,%�k Hardpan ❑ <br /> Previous Application 4ade: Yes E] NoK New Construction: Yes No E] FHA/VA: Yes ❑ N <br /> TYPE OF INSTALLATIiPN AND SPECIFICATIONS: <br /> (No septic tan, cesspool permitted if public sewer is available within 200 feet.) <br /> tic T Distance from nearest well_______________Distance from foundation___.........____....Material______________-__-__-________._______________. r <br /> " - -+4o-. of compartrrtents---------- ---------------Size---•----------------------------Liquid depth--------------------------Capacity__------•--•--------- <br /> posal F d: Distance from nearest well_______________Distance from foundation....................Distance to nearest lot line--------------_ A <br /> Number of lines-----------------------------------Length of each line_______________________._____-Width of trench_______________-_________________- <br /> (((��� '�' Type of filter material------------------------- of filter material--------_--------------Total length___________-_________.________............ <br /> Seepage Pit: Distance to nearest/well_-l'_Z_.......Distance from undation__,��_ Distance to nearest lot line...... <br /> Number of its---_,L----``"- --- Linin material... -----Size: Diameter__- • <br /> P 9 �� Depth -'----------------- <br /> Cesspool: <br /> = ` <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_____________________________________. <br /> ❑ Size: Diameter_------- - --- ----- - Depth---- ------ -- ---- - --- ------Liquid Capacity- ------- -----gals. <br /> Privy: 1, Distance from nearest well __ ____ Distance from nearest building_________---------------------------- <br /> El <br /> _ __ ________________❑ Distance to nearest lot line y - --------------- ,---- ------------------------------ ---------- ----- ----- <br /> Remodeling and/or repairing (describe):---- ------ --- --- ---- <br /> ------------------------------------------------------------------------ --- ---------­1 <br /> __ -------------------------------------- ---------------- ----------------------- - <br /> _____________________________________________________________________________________________________________________________i__________________________-_________________________________________-___________________________ <br /> ____.___________________________________________________________________________________________________________.________' __________________________________________________________________________________________________-__ <br /> I hereby certify that I have prepared this application ancL that the" ork will be done in accordance with San Joaquin County <br /> ordinances, 'State laws, and rul a regulati s of a Sa oaquin Loc' t ealth District. <br /> --------(Signed) ; (Own a /or Contractor] <br /> By:------------ <br /> - -- -- f •------------------------ ---- (Titlej-_ r•'------- --------- <br /> - - - -------- ------- <br /> (Plot plan, sh g s o lot in of system in relation to wells, buildings, etc., can be placed on r ersq, e). <br /> FOR DEPARTMENT USE ONLY -. <br /> APPLICATION ACCEPTED BY----------------------------------------------------- -------------------------------------- - DATE.. Y ---- -------- <br /> REVIEWEDBY------------------------------------------------------------------------- - ---- - - ----- DATE_ <br /> BUILDING PERMIT ISSUED - - DATE. --------- ---_--------- <br /> Alterations and/or commendations: --------- -------------------- ------------------------ =` <br /> ----------------------------------------- - ----------------- -----­--------------------- - -------------------------------------------------------------------------------------------------------- <br /> °1 <br /> -��.— ± 071-----�?cr--1-----------ti---� -----S-�Q��.,� <br /> ------------------ ----;Pk" <br /> � ---- <br /> ------ ` <br /> ------------ - <br /> Jr <br /> FINAL INSPECTION BY:----- <br /> -- -------- D t .x. <br /> SAN UIN L CALHEALTH DISTRICT . <br /> ' <br /> c - <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street `5— <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M , Revised 1.57 F.P.CO. j;' <br />