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APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (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 /> epric,�i <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCAWTI ---------- ------------------------------------------- <br /> -------------- -------------------- ------------- ------------------------ ---- <br /> ------------ --------------- Phone----------------------------------- <br /> Owner's Name--------------------- <br /> Address--------------------- e <br /> - -- --------- '0 ---------- ------------ - <br /> ---- -- -- --------- Phone---- ----- <br /> Contractor's Name_____ <br /> , 40 SII <br /> Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ❑ Motel El Other E] <br /> Number of living units: Number of bedrooms Number of 'ahs Lot size ---(5-6rx----/—?J <br /> Water Supply. Public system El Community system -E] Private !;<elpthI%,f <br /> to Water Tab ft. <br /> Character of soil to a depth of 3 feet: Sand 0 avel 0 Sandy Loam Loam E] Clay E] Adobeardpan E] <br /> Previous Application Made: Yes 0 No �New Construction: Yes No 0 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> �Sepfic T nk: Distance from nearest well----------------!Distance from foundation--------------------Maferial' <br /> ;i��" OP <br /> No. of compartrents-------------------------!Size--------------------------- Liquid d fh--------------------------Capacity------------------ <br /> Disposal Fiel Distance from nearest well-- ------,Distance from foun�a�- -X- _______Distance to nearest lot line---Sr------- <br /> Number o� lines____ _-_-'Length of-each iine-­j,'Ye--------- ---.Width of trench-- <br /> er - T I.,- ---------------------- <br /> Type of filter material-- -- Depth of filter mafe'ria'l------/-AXO-2----Total <br /> length___-_(0--a____________________________,...,. <br /> s An <br /> Seepage <br /> -a---------------------------- <br /> Seepage Pif: Distance to nearest-well----------------------Disfance4rorn foundation-------------­----Distance to nearest lot line_______________-_ l/1_ <br /> ❑ Number <br /> ine----------------- <br /> Number of pits----------------------Lining material----d-----------_----Size: Diameter----------------------Depth--------------------------------- <br /> Cesspool-, Distance from. nearest well_______---------Distance from foundation-------------8---Lining material____________________-_-----_________. <br /> ❑ <br /> aterial------------------------------------- <br /> ElSize. Diameter--------- ---------------------------Depth--------------------------------------I-------------Liquid Capacity----------------------------gals. <br /> rivy-: (A ' <br /> P <br /> Distance from nearest well-------------------------- -------I--------------D;stance from neared building---------- ------------------------------- <br /> F1 Distance to nearest lot line <br /> --------------------- --------------- <br /> ---------- <br /> ------------ ----------------------------- <br /> --------------------------L---- <br /> -------------------------------------------------- <br /> - <br /> Remodeling and/or repairing (describ - ------------ --------- - --- - - �------ ---------------- ------------- <br /> -------------------------------------------------------- --------- -- 0-- -- - ------------------------- <br /> ----------------------------------- ------- ------------------------------------------------------ <br /> - -------------------------------------------------------------------•---------------------------------------- <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& and rules and ri;g6lati6ns of the San Joaquin Local'Health District. <br /> (Signed ep %� 4d <br /> ------------ ------- ------ ------ .......rlgk"O,� <br /> 10---<44- ----—---- ---- ------- ---(Owgpr and/o C f t <br /> on rac or <br /> a. <br /> . . . ......... <br /> By:--------------- 7e----�41e'--- <br /> ----- --- ------------------------------------------------------------L--------{Title)-------- e-------- <br /> --------------------- ------------------- <br /> (Plot plan, showing size of lot. location 'of system in relation to wells, buildings, etc., can be pl6ced on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B <br /> I -------------------- ----------------------------------------------------------- <br /> ---------- DATE-_ ------------------------ <br /> ---------------------------- <br /> REVIEWEDBY-------------------------------- ------------------- --------------------------------=------------------------------------- DATE----- <br /> -- <br /> r !�F---- --------------------------------------------- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------- <br /> Alterations <br /> ATE----------Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------- <br /> ------------ I I . - - - . <br /> ---------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> --------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------ --------------------------------------------------------------------------- -------------- ---------------------------------------------------- <br /> --------------------- ------------------------- I <br /> ----- ----- -- ------------------ ----------------------------------- ---------------------------- ------------------------------------------ <br /> I <br /> FINAL INSPECTION BY:---------------- ------ ------IF------------------- Date...... 7/1 <br /> 4 ----- ----------------------------------------- <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 /> E5-9-2M 8-51 Revised W-2100 <br />