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APPLICATION FOR SANITATION PERMIT Permit No. _ ____ <br /> 11 (Complete in Duplicate) (P <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 /> This application is made in compliance with County Ordinance No. 549, <br /> JOB ADDRESS AND LOCATION_______ _ --�_--__- -- - -_E--- --_ <br /> p�� �! <br /> Owner's Name-------- LM64'------1 - - ------------------------------------------------------------------------ ------ Phone-------------------------•---------- <br /> Address.---------- <br /> -- ----------- <br /> Contractor's Name -------------- - / -- - - - --- --- ------ Phone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court f] Motel ❑ Other ❑ <br /> Number of living units: __ __ Number of bedrooms ___Number of baths /___ Lot size --- 4-_-,e` _�'Q_- ------------------ <br /> Wafer Supply: Public system ❑ Community system R�Private ❑ Depth to Water Table -Y-&ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No R?" New Construction: Yes ❑ No [SHA/VA: Yes ❑ No @4-- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> sap#ic Tank: Distance from nearest well-----------------Distance from foundation___________________Material------------------------------------------------- <br /> ✓ No. of compartments-------- -----Size------------ ................-.Liquid de th----------------- --------Capacity <br /> Disposal Field: Distance from nearest well-°�' distance from foundation __ .________.Distance to nearest lot ,._______ <br /> Q� Number of lines_____________________ _______ _ Length of each line-------- a-!__ .Width of trench------/� �`:________.- <br /> Type of filter material�'y .-Depth of filter maferial___ "� -___Total length_______ -`-______________________ <br /> See e Pit: Distance to nearest wef!----------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> r <br /> r Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------. 1lti4 <br /> ,'Cesspoo: Distance from nearest well______________Distance from foundation____________________Lining material-_------________________-_.________- <br /> ` ❑ Size: Diameter--------------------------------------Depth--------------------- ------ ----------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well---------------------------------------------_-_Distance from nearest building----__.._________________-__-------------. <br /> t' ❑ Distance to nearest lot line----- ----•---------------------------------------------------------------------------r--------------- <br /> ��r '�+ <br /> Remodeling and/or repairing (describe)--- ---- ------------- ------- -- -----------•-•----------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------=---------------------------------------------------- ---------------------------------------------------------------------- <br /> I <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 lawsaandd les end regu'ati s of the San Joaquin Local Health District. <br /> (Signed)---------------------- <br /> - -- -' ----- -------------------------------------- <br /> - --------------------''4Qwn@ #vdjvriContraetor) <br /> By----------------------- ------------------------------------------{Title)----- <br /> (Plot pian, showing size of lot, ati!n__,�sysfern in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------- ------ --- -------- DATE------ -- <br /> - ---------------V---- <br /> -----------------------­--------------------------- <br /> - <br /> REVIEWEDBY------------------------------------- ---------------------- - --- -- ---------------------------------------- -------- DATE---------- <br /> BUILDING PERMIT ISSUED--------------------------------------------- ---- ----------------------------------------------- DATE------ <br /> Alterations and/ormmendations: --- --------- . <br /> df + <br /> ---------------- --- - ------------ --- -- --• ------- <br /> -- -r�. ------------------------ <br /> -------------- <br /> -------------- -------- ------ - - =-�c�1-- ----- <br /> ------------------------------------Ir-.1------ -------------------------------------- <br /> FINAL INSPECTION BY:----- - Date-------------- <br /> V SAN JOA4 UIN 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 , Revised 1.57 F.P.CO. + <br /> t <br />