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APPLICATION FOR SANITATION PERMIT Permit No. __-_ -_-_3.3_._._ <br /> (Complete in Duplicate) 3 <br /> Date Issued ---- i <br /> Applicaa-ion 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 /> JOB ADDRESS AND LOCATION-------3-,3- 'r-----f ---------- ----- <br /> OwnePs Name_ f� :: = -:__y Phone------------------------------ <br /> Address <br /> --------------- ---- <br /> r <br /> rS� ISj ----------------------------- .. __ M <br /> Address..----•-------� -------- - ------ --- ' ------------- - ------------------------------- •---•---- <br /> Contractor's Name } 17 ' ..�+, 4 =: -' Phone__ d•_- - -9Ce`7 <br /> - ----- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court.❑ Motel ❑ Other ❑ <br /> i Number' of living.units: __r____ Number of bedrooms __2._ Number of baths --- Lot+sizeX-1._�--____________________________--__ <br /> Water Supply:, Public system. P0 'Community system ❑ Private ❑ 'Depth to Water 4Table t_ -_-- ff. ry <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay-Loam❑_,Clay ❑ Adobe[3 Hardpan ❑ <br /> Previous Application Made: Yes,[-] No [Z New Construction.: Yes [4 No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: T <br /> 1. '(No-septic{tank#or cesspool permitted.if public sewer is available,within:200.feet.) <br /> Septic Tank: Distance from 'nearest well.- —___Distance from foundation---1-Q_--_---___-Material--- __-->__. <br /> } No. of compartmentsll� ___.`_ .M <br /> W; P s T Size = _, = Liquid depth - iCapacity aQ <br /> Disposal Fie#d: Distance from nearest well_._._--_._____Distance from foundation-____ S- --_.Distance to nearest lot line,___1_Q---_---- <br /> Number of lines.__,__ _______'_ Length of each.line_.---a2_67'___i!- - -.--Width of trench-_ '�_ <br /> Type .or filter material.__ -___-�� Depth of filter-material--_--_����__ ____Total length__ .__. ._._.____________.._ <br /> Seepage Pit: Distance to neatest well_}----- -__________Distance from foundation_..� .t___.Distan`+e to nearest lot Iine._.I4____.__ <br /> p 61) <br /> I�__1----Lining material-�CY-k/Lh�k eter-=--- S_$..------..Depth____.:�.47-=--------------- <br /> I�,umE�er of its.____:.__ � � ize:.Diam ) r - <br /> i v � r11 <br /> Cesspool: f Distance from nearest well___-=:_-___-_,._Distance from foundation_____:________:__.Lining material___._______________________________. <br /> y Size: Diameter ------------------- Depth liquid Capacity = gals. <br /> ❑; <br /> Priv # Distance from nearest <br /> ❑f �. ._. ., _ _, well_-_-_-_-_____-_-_-__- ' <br /> - -- -- - Distance from nearest <br /> '•building___-_ _ _ <br /> T-Di.s.tanc_e. to nearestlot ine­----,m-_--.---_-,-.--.-,-------- -------------------•--- -------•---------------------- -••-------__---------------- <br /> Remodeling <br /> �.. <br /> and/or repairing (describe):_- --------------- -------------------------------------- <br /> - <br /> I <br /> = - :---••--------------------------------- <br /> ---•------=-----------•----••-----------------------------------•----------------•-----------;---------------------------i- ------------------------------------------------------•----- <br /> I <br /> --------- ---------------------- --------------------------------------------------------------------------------------------------------.--------------------------------------------------------------------------------- <br /> -------------------------1--------- ------------------------------------------------------------ ------------------------------------------------ -------------------------------------------------------------- <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, Stat ws,,and rules and regulations of the'San Joaquin Local Health District. <br /> (Signed) i {Owner and/or Contractor) <br /> ------------------ ..---(Title) i <br /> y�;�-- { 1--------_ ------------ <br /> (Plot plan,`±:howing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). _ <br /> ( i FOR DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY-------------- ----- _ _.._.. ------------------------------------------------------------ DATE------- y '5------------ <br /> REVIEWEDBY------------------------- ---------------------------------------------------------------- ------ DATE----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED---------------------=----------- ------------------------------------------------------------------.- DATE----------------------------------------------------i-------- <br /> Alterations and/or recommendations:- _______-------------------------- ' ^ "' -_-__-___- <br /> t ------------------------•-----•-----------•-------i----------------- -""-- <br /> --------- --- ---------------------------------•--------------- ----------------------------------------------------------------------------------------.._.---•--.-.---•----------------------------------------------- <br /> s I <br /> k----------------------------------•--------•-------------------------------------- ------ -----------------' ---- --- ----------------- -------------•------------------------ <br /> t <br /> FINAL"INSPECTION^BY........_..�-�--- ------- Date'._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 /> ES-9-2M Revised W-2100 <br />