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APPLICATION FOR SANITATION PERMIT Permit No. .//-/.G/_)_. <br /> (Complete in Duplicate) Date Issued ._ ;' A----- <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 Qylinance No. 549. <br /> y '� <br /> JOB ADDRESS AND LOC CAT N /.. ----------------- <br /> (------- <br /> Owner's Name d/� `s , !------ -----=--------- --(-�-� ------ Phone:---��S- � 7 <br /> Address -------1,.t.!_--•------ ----------- ------ _!.._------------ ................................................................. <br /> Contractor's Name---------------•------ ---------- -------------------------------------•---------------•--------------------------------. Phone...........................------ - <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _.I_-- Number of bedrooms --Number of baths --f.-- Lot size ------ <br /> Water <br /> -.-.Water Supply: Public system, 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 F] <br /> Previous Application Made: Yes*E] NoX New Construction: YesK No E] FHA/VA: Yes E] NoX. <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) D <br /> Septic Tank: Distance from nearest welL".. .__-.Distance fromfoundation. :_-/ -------- <br /> Material!�_� ______ <br /> No. of compartments------�___.___----Size--_-------------- -l.�_._Liquid depth___._.._. -._______Capacity_._.__ d __. <br /> Disposal Field: Distance from nearest Aell------ -----Distance from foundation. __..-_.Distance to nearest to line�.._�~.-- <br /> N ° Number of lines---------...�.....................Length of each line--_-_.___�� Width,of trench-----.- -..--.- <br /> Type of filter material. ?__Depth of filter material---.._l�-_-----.Total length------------------------------------------ <br /> Type <br /> Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- <br /> F1 Number of pits-.--------------------Lining material-----------------------Size: Diameter-----------------------Depth-_.-_________---..--..___----- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------. (1V <br /> j <br /> ❑ Size: Diameter--------------------------------------De th----•-----------------------------------------------Liquid Capacity----------------------- <br /> --•--gals <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.._--___-_.--..--._-.--.-----------------. <br /> ❑ Distance to nearest lot line--------------------------------------------------------------------•- <br /> Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- <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, Sta laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed, /-- - - ......Z___ -------------------------------(Owner and/or Contractor) <br /> BY� -------- --------- --------------------------------------------(Title)--------------------------------------------- ------------- <br /> (Plot plan, owing size of lot, location of sys em in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------- - --------------------------------------------------- DATE-------� - <br /> -------------------- <br /> BY------------------------------------------------ - ------- �--------------------------- DATE-------- -- ---... --- -- <br /> BUILDINGPERMIT ISSUED--------------------------------------•----------------------------------------------------------- DATE----------------------------------------------------------- <br /> Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------.------------------------....................................... <br /> ---------- -- -------------------­--------------------------------------------------------------- <br /> ----------------------- -------- ---------------------------- ------------------------- ------------------------------------------------------------ <br /> FINAL INSPECTION BY---------------- L - Date-.----�- i <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 />