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; <br /> U' APPLICATION FOR SANITATION PERMIT Permit No. <br /> tAIQ.. _.z <br /> (Complete in Duplicate) <br /> u Date Issued <br /> r <br /> pplication is hereby made to the San.Joaquin Lova! Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinanc 549. <br /> JOB ADDRESS AND LOCATION------ G�(?,S-ra 1f I - " - ��r ----------------- <br /> Owner's Name---------------------------------- -�---•-- ----- ----- --- i, --------------------------------- Phone------— <br /> ----------------------- <br /> Address----------•--------------------•----------- �- C 7 --------------- �/ ----------------------------------- <br /> %. ---- <br /> (� <br /> Contractors Name---------•-----------••-- 1 ./']--------_- - =±<r Phone Q <br /> Installation will serve: Residence K, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___r___ Number of bedrooms 3-_ Number of baths -J___ Lot size ___,/_6- ---- ___�------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _t <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑. ..Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA_ Hard an <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No <br /> pP <br /> TYPE FINSTALLATION AND SPECIFICATIONS: y <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> k <br /> is Distance from nearest well____---_---------Distance from foundation-------------------_Material--------'__-_--_______-________________._.____-. •� <br /> .Q <br /> No. of cornpartments-------------------- f Size'----------------------------- Liquid depth--------------- - --------Capacity----------------------- <br /> 0eepage <br /> al Fi d: Distance f ofn nearest well_________________.Distance from foundation________.__„ __.Distance to nearest lot line_____________.__.� Length of each line----------------------Y-----:Width of trench----------------------------------- <br /> Type of filter aterial____: ____ _.Y____._._Depth of filter material_--`_______________':.Total length_°_.____.__________Pit: Distance to ne resf ,weTi_�--Distan- M foundation_ _B Distance to nearest lot line____ ____ <br /> Number of pits------1--------------Lining material"'�_�---_Size: Diameter..... _ __r'_.Depth-. ------------ • <br /> Cesspool: Distance from nearest well----___----------Distance from foundation---------------------Lining material------------------------------.______ <br /> ❑ Size: Diameter------------------ ------ ------Depth---------------------------------------------------Liquid Capacity------------------ ---------gals. <br /> t <br /> Privy: Distance from nearest well______________-----------------------------------Distance from nearest building----------------------------------------- <br /> Distance <br /> ____._.____.______________._-.- --_Distance to nearest lot line-------------------- -------------------------------- -- <br /> ---------- ------------------------ ------------ <br /> e nd/nd/or repairin de rll�e}_________________________ <br /> ------------ <br /> ------- - --------_ --- --�------ ----•--- <br /> �-�- <br /> - ---- ••-- ---------------------------------------=-----•---------_---�---.--;,----�---- ------------------- ------------------------------- <br /> . <br /> -- -- <br /> 4 __________________________________________________________________•_---_----_-____________ <br /> --------------•- ------------------ ----------------- ------------------------------------•------------------------------------------------------------------------------------------------------------------County <br /> I hereby certif that I have prep red this applic on and that the work will be done in accordance with San Joaquin Coun -3 <br /> ordinances, State la an rules and egulations of t San Joaquin Local Health District. <br /> . t <br /> Contractor) <br /> - -- <br /> (Signed)_-----------•-------------•- --- -------- f <br /> By:--------------------------------------------------- ---- �_ Zlt <br /> By: <br /> plan, showing size of lot, location of system in relation tow s, buildings, can be p ced on reverse side). <br /> FOR DEPAR ENT USE ONLY 1 <br /> APPLICATION ACCEPTED BY------------- ------------------ [/f1 DATE <br /> REVIEWEDBY-------------------------------------------------------------------------------------=---------•-------------------•--•-- DATE-------------------- ----- -------•----------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------- � ----------------- DATE----------------------- <br /> Alterationsand/or recommendations-------- -----------:___----------------- =---•------------------- ----------------------------•-------------------------------------------------------- <br /> -------­---------- <br /> ------------:-------------------------------------------------------- -- ------------ ------------------------------- --------------------------------------------------------------------------------------•----------------- <br /> ----------------- --------------------------- •--------•---------- <br /> -------------•----------------------------------- 6i� ..........-- ^ ----------- -------------------------------- <br /> FINALINSPECTION BY------------------------------------------------------------- Date- .- f --------- --- ----------------------------------------- <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 10-52 Revised W-2100 <br />