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APPLICATION FOR 'SANITATION PERMIT Permit No. ___ /...... <br /> (Completein Duplicate) 1 y�,�/� <br /> Date Issued ...?M <br /> 6 <br /> hpslaca ion is is by mad courthe San I ante with Joaquin Local HealthdDistrict f or a permit to construct and install the work herein described. <br /> is Pp P Y <br /> JOB ADDRESS AND LOCATION.___7�4..... ,4..... <br /> Owner's Name " ---- -- ---------------- -------------------------------- ----------------- Phone.------------.----------------- <br /> Address --- <br /> -------- <br /> --------•----�••- - ------------------------------------------------..-..... <br /> Contractor's Name__ <br /> --------------- -------- <br /> ___________ Phone. <br /> Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: __/__ Number of bedrooms oZ-- Number of baths ..!-_- Lot size ................................ <br /> s <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _" '3`ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe @9­19ardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ No W?'0'7FHA/VA: Yes ❑ No R— <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> peic ank: Distance from nearest well-----------------Distance from foundation--------------------Material_-_.____-__-__--.---___•_•----_--..--.._._._._._.. <br /> No. of compartments--------------------------Size--------------------------------Liquid depth_-------------------------Capacity--------------------- <br /> r �� <br /> Dispo 7, , ` Distance from nearest well---�-_----Distance from foundation____�y--------Distance to nearest,,jo''f``line._..��o�-'.`.__ <br /> Number of lines__________ ____ Length of each line---- 4r mr. _.___._.Width of trench...,�'�`'_�� <br /> Type of filter materia6�-_Depth of filter material_../ ------------Total length____--..; ✓_w..................... <br /> teepage Pit: Distance to nearest yell __-- -----------Distance fy 0 at ion....�0._.___.D•stanfe to nearest lot lin e_..__... <br /> _____ <br /> Number of pits---.---/--------------Lining material./,2__0�/�___ maize: Diameter- _--,--------- <br /> . �� Depth_____-�,Q__._•-------_---- �, <br /> Cesspool: Distance from nearest well_________________Distance from foundation___._____-__-_--_.Lining material...._-__- .__.__-...___,.....,_.. <br /> ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------Liquid Capacity------_--------------.....gais. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_.-------_-------------.-............... <br /> ' Distance to nearest lot line------------•-- --- ----- ---------------------•-----------•--------------------•--•-----•---•--•-----•--------------•-- -----•----•------ <br /> Remodeling and/or repairing (describe)-------------��i2 �,/,' �j� <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 laws, an4 rules and regulaltohs of the Sa Joaquin Local H th District. <br /> (Signed) .._` -'� -------- ow- Contractor) <br /> (Plot plan, showing size of lot, I ion of system in relation to wells, buildings, etc., can be placed on reverses' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------------------- ------------------------------------------------------------------- DATE------------------. <br /> REVIEWED BY------------------- ----- - ---- -- ---- --------------------- <br /> DATE.... - <br /> BUILDING PERMIT ISSUED - DATE - - -----------------•-------.. <br /> Alterations and/or recommendation ' ------------------------------- <br /> -----------------------------------------------•-------------- --------------------- ----- -------------------------------------------------------------- -6 <br /> ---.............................. <br /> R ------ --- --- - . ---••-....._. f <br /> =...:. <br /> am- <br /> ------ <br /> FINAL INSPECTION BY: C--- -----'--- Date------`�'"`''� -------------- <br /> - <br /> F <br /> ' SAN JOAQUIN LOCAL HEA TH 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 />