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APPLICATION FOR SANITATION PERMIT Permit No. ..... <br /> (Complete in Duplicate) pate Issued <br /> -. t.. .w......•. — w <br /> Applica-1-ion is hereby mads to the San Joaquin Local Health District for a permit to ycsuct an installwor en d� ribed. <br /> This application is made.in complian a with County Ordinance No 549. -------------------- <br /> JOBADDRESS A D LQCATI N_____ l.__"-""-- - ----�-- - ------- , --------•---------- - --'______ --_______-_-____.".._-_____••____ ^T <br /> •--- - ------------- ---- ---- <br /> - - -- <br /> Owner's --- - '" ----------------------------- .--__ Phone _. _ ,----- _ <br /> :. ." <br /> • � ----- ---`------------------=---------- ----- <br /> Address C € -------------•----•----------------------- <br /> f - --------- <br /> Contractor's Name__.- ---- j ------ Phone-----------•----------------------- a <br /> Installation will serve: .Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel�01Number of living units: __ -__ NuAber of bedroom0__ ___,Number baths -____-__ Lot size ______"__________ _________________ <br /> Water Supply: Public'system'❑ Community system ❑ Privateepth to'Wafier Table __..____ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam © Clay Loam E] .Clay E] Adobe v Hardpan E] ' <br /> Previous Application Made: Yes E] No B/ New Construction: Yes Q`No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> (No septic tank or cesspool permitted if_pub'lic sewer is available within 200 feet.): 4 <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation-_______--W____---.Material-------------------------------------------------- <br /> - <br /> _ ___________________________________ <br /> ❑ No. of compartments--------------=-- Size. ------------ ----- Liquid depth Capacity Y, <br /> Disposal Field: Distance from nearest well ---.------------ <br /> Distance from foundation,_Y _ Distance to nearest lot line----------------- <br /> ❑ Number of lines__----:-------------'--------------Length of each..lin'e-------------------------' --.Width of trench---------------- ........... <br /> Type of filter material _-'__ ___ ___, Depth of filter merial_. _____Tota'I length____________________,________________.__ <br /> su+ .w . rwn r ___+rwlw a <br /> Seepage Pit Distance to ne _ _Distance from foundatio _ Distance to nearest loft line- "_____..___._ <br /> arest:well -_____ <br /> ❑ Number of pits__-- ----- Lining material---------------- ----Size: Di��ete� Depth- .----A- ---- +� <br /> r g lJ �r� <br /> 3 nn <br /> Cessp Distance from nearest wella�f.< D stance from foun�af ion _-°t '"'-_.Linirig'matel--------_____ _________ <br /> #X I.__--___--Depth---------------- '_ ___.� ' Li ui.d Ca acit �'f __gals. _ <br /> Size: Diameter---- '" l t- q p Y T <br /> DlStance'from nearest building <br /> Privy: Distance from nearest well----------------=----------------- ------------ 9 <br /> ❑ - w---�---Distance to nearest;l'ot'h e <br /> 1 <br /> c L <br /> y.i.yrwnr rr.r* <br /> Remodeling and/or repairing {describe). -' _-- � ----- i <br /> -1.4J <br /> y = •--------- - -- - ------ <br /> - - - -------------------------- <br /> -------------�YI�/- -- ------------ ----------- - <br /> L <br /> I herebycertifythat I have re tired-this-a lication and that the work •- - e i - Sa <br /> - =- ----- ----------- •p ene in ac n 1 an Joaquin ounty <br /> will-be d cords ce-w'th 5C <br /> ordinances, tate lws, and rules and regulations of the San Joaquin Local Health Distil . <br /> �__--(Ow4, 11 <br /> ner and/or Contracfior) ' <br /> (Signed)- <br /> ....... <br /> Signed) ° - — - <br /> r <br /> --- •- -------- --- Title---•"----------------------"-------=--;--------=-----=---------- <br /> $Y: y------------ y--•- ---- - ( ) <br /> (Plot plan, showing size of lot, locatloll system in relation to wells, buildings; etc.; can be placed on reverse side)! <br /> FOR DEPARTMENT USE ONLY <br /> DATE ----4 E --------- <br /> APPLICATION ACCEPTED BY ------------ ------- --- { <br /> REVIEWED BY---=-----------------------=-- ---- --- ----------------------- ---- = = DATE :--- -- = <br /> BUILDING PERMIT ISSUED-- -------------- -----------------------------------------------------------` DATE Qf; _ = <br /> Alterations and/or recommendations-------------------------•------ --- - ---•---------•--•---------•------- j <br /> --•------------- --------------------•----------------•---------------- ------.............................. <br /> - M1________________________________________________________________________________________________ F <br /> ' __________________ ------------------------------------­----- ------------------------------------------------------ <br /> "7 ------------------------ <br /> FINAL INSPECTION' BY:' "' <br /> •- .!_... Date - - = ----- <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 />