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y APPLICATION FOR SANITATION PERM Permit No. <br /> (Complete in Duplicate) <br /> Date Issued ____I-yiv , <br /> L- /3_Y <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 /> • i 5 S j <br /> JOB ADDRESS AND LOCATION--- ���£ �--------5�--'�--'j----0-------��'�{ � f�------------------------------------------------------------------ <br /> Owner's Name--------- �'s �'�------------------------------------------------ <br /> �._��-------�.�.-lY-- -�=-�--• --------------------------------------------- --------- <br /> Address---------- F t3 -L ' ----- 0--- -:------------------------------------------------=-------------- -------------------------------------------- I <br /> Contractor's Name--------. --------------------------------- - -------- <br /> -- ---------------------------'- Phone--------� � � '� <br /> Installation will serve: Residence N Apartment House ❑ Commercial ❑ Trailer Court ❑ MotelE] Other E]Number of living units: _ .___ Number of bedrooms __d____ Number of baths -,/ <br /> Lot size -' . 0'. ----------- <br /> Water Supply: Public system ❑ Community system ❑ Private Z Depth to-Water-Table---------ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9 Hardpan ❑ <br /> Previous Application Made: Yes ❑ No X New Construction: Yes [M No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Y <br /> Septic Tank: bistance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- <br /> No. <br /> -_---- ___________________-___----------___--.No. of compartmems--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well--AZ-V--,.-Distance from foundation__----- ________Distance to nearest lot line-_-,�_______ <br /> Number of {fines__ <br /> ------______/__-_________-___---Length of each line------i_G _-______,--------Width of trench_-,--- .� _ __-_____________ <br /> 4 Type of filter niaterial----1_:�_ fi__ .9�`_Depth of filter material-----/3-_"_------Total length-------- _____________ <br /> ---------- --- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation----................Distance to nearest lot line----.------------ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth---------_---------.------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining'material_________._________________--_g__�_ <br /> a-_l-s-.- <br /> ❑ Size: Diameter--- ------------------------- --------Depth------------------------------------- -------------Liquid Capacity----------------------- <br /> Privy: well <br /> 4 <br /> Distance from nearest well_______________________________- .___.-________Distance from nearest building___________________________.-____________- <br /> Distanceto nearest lot line----------------------------- --------------------------------------------••----------------------------------------------------------------- <br /> y ; <br /> Remodeling and/or repairing (describe):__.__.--------IT,9 -e, D.e <br /> --------------------------•-•--•-•---------------------------------------------------------•---------------- -------------------------------•-------------------- -----------•------------- ----•-------- <br /> ------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------i---------------------------------------•-------------------------------------- <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, and rules and regulations of the San Joaquin Local'Health District. <br /> 1 _________-_--_-___________________ __Owner and/or Contractor <br /> [Signed} -------------------- --- _/ } . <br /> x�..— r ---------------------- <br /> By:•_-.(�!�_-►�--:-- -�L�="--------J��.✓L-��------------------------------------------------------------------[Title}__ �w��t,�1 -- -�- - <br /> (Plot plan, showing size of lot, locatiodof system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTM 7 USIr NLY <br /> APPLICATION ACCEPTED BY- ---- DATE--------- ­ � �-�------------ <br /> REVIEWEDBY-----------------------------------------------------------------------------------------------------------------------------• DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED--------------------------•------------------------------------=------------------ ------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations----------- --------------------------------------------------------=----------------------------•--------- <br /> - � <br /> - ---------------------.�--------------------------------- ----- ------ - <br /> ------------- <br /> -------------------- <br /> � <br /> .P. -------------- R--------- -- ---------- ---------------- ---- --------------------- -----Xw_, - <br /> - - ----- <br /> -� �``-ems <br /> ! FINAL INSPECTION BY---------------- ----- ' = -- --------------- Date------ ---------------------- <br /> I <br /> ---•----------I SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> v60 <br /> 130 South American S+feet 300 West Oak Street 132 Sycamore Street 814 Nort♦ G" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> 1=S-9-2M 8-51 Revised W-2100 <br />