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APPLICATION FOR SANITATION PERMIT er t No. f SL <br /> 0 <br /> (Complete in Duplicate) / <br /> Date Issued __--______ [�{iS'„� i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. a <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION p ----- .c '- --------------------------------------------------------------------------------------- <br /> Owner`s Name [f r ------ Phone------------------------------------ <br /> Address-•--••------ -- = f ----- ----- ---------------------------------------------------------------------------------------------••---------------------------------- <br /> Contractor's Name_-- ------- .......__ <br /> ------------------ Phone rD__ L <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ frailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---/___ Number of bedrooms ___ Number of baths __._f_ Lot size ---- _ ____ __ __`- __4 ---__---------------- <br /> Water Supply: Public system [Community system ❑ Private ❑ Depth to Waterable ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®.�ardpan ❑ <br /> Previous Application Made: Yes ❑ No [a—`New Construction: Yes ❑ No I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: f <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank- Distance.from nearest well_________________Distance from foundation__+----------------Material------------------------- ----------------------- <br /> ❑ ' No. of compartrrnents--------- ------------ ---Size--------------------------------Liq d depth--------------------------Capacity----- - --------------- <br /> Disposal Field: Distance fromnearest well-f1_0_-V__Distance from foundation__/_rt-----------Distance to nearest lot line--- <br /> Number of lines____________ n Len th of each line_________6--p--- -------Width of french----- -� ------.---------- <br /> Type of filter material_,,-&�--Depth of filter material___ ______-__-__Total length-_-_-____,,�__�'________________ <br /> Seepia 'Pit: Distance to nearest weli----1_o�>�-------Distance from, j&ndata -------- <br /> to • ___ ___ <br /> Number of pits----------f----------Lining materia! .____Size: Diameter__'?______________Depth------A5--_-__- ------_L. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- materia____-_____-_________________--_-__.- '.,. <br /> Size: Diameter-------------------------- <br /> ❑ ------------D,eptly----------------------�---------------------------Liquid Capacity----------: -----------....gals:' <br /> Privy: Distance from nearest well------- <br /> -----------------Distance from nearest building_----- --------._._._.--__._---____-. 3 <br /> ❑ Distance to nearest loft line-----------------------------------------�! `'--------------------------------------------------•---- --------•---------------- <br /> Remodeling and/or repairing (describe):------------ - ------- = z � -----------•------------------- =-------•--- <br /> -------------- ---- ---- ---- --- <br /> ----------------------------------------------- ------- <br /> -- -------------------------- <br /> -----•--------------------- --- Q ----- ---- -------------------------------------------------- <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 laws, and rules and regulations of the San Joaquin Local Health District. , <br /> I <br /> (Signed) <br /> � - � - I <br /> {Owner and/or Contractor) <br /> = -- -- ------- <br /> By:-----------�t- - ------ .. - ----------- <br /> (Plot <br /> plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- � --�� -------------------- DATE-------- &,/-(--- -- ------------------------------- <br /> REVIEWED <br /> -5----REVIEWED BY-------------------------------------------------- -------=-------------------------------------------------------------- DATE----- --------------------------------- <br /> BUILDING PERMIT ISSUED ------------------------------------ DATE - <br /> ` <br /> = --- ' -" <br /> Alterati ns and/or recomm_enr�. ati ----------------- + �^ <br /> '" _ m.AR?1 z�--__ ___�-_----------- <br /> _ r!nn� A --------- <br /> - . d r ' <br /> -r---------------------------------------------------------------------------------------------- <br /> --------------•--- --------------------------------------------. .__--------------------------------------- -•----------------------------------------------•------------------------------------------------------------ <br /> FINAL INSPECTION BY:------ --------------------------------- Qate_ - <br /> E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT III <br /> 130 South American Street 304 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M 5-51 Revised W-2100 , <br />