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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued ------------- <br /> Application <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 /> 2 Ve 4 A• 5 ' <br /> JOB ADDRESS AND LOCATION----- �2-- ------------------r------------------- - -- - <br /> Owner's Name---------------- �� --------7- - #'r---- -------------------------------- <br /> -- - -- - �---- --------------------------------------------- - - --- -- -.__ Phone ---- <br /> Address---------- -- --------------------------------------------------------------------------------------------------------------------------------------------------- •-------- ---•------- <br /> Contractor's Name---Q" '"----------------------------------------------------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ___/__ Number of bedroom_ s _-__--_- Number of baths ________ Lot size .-.5-- ------ --- -- ------------------ <br /> Water Supply: Public system [�Commun'ity system ❑ Private ❑ Depth to Water Table -------- ft_ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9300*oHardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes 1910 ❑ FHA/VA: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (Nose tic tank sp lP sted.LL. public <br /> saleI n✓20D feet.) <br /> Se tickDtancefromneare ��ne Distancefrom foundation-----14?-------Material .. • <br /> rNo. <br /> of compartments depth----�----_------------Capacity....,?____- -_- <br /> osa <br /> Dis l ield: Distance from nearest well-�4 "�'-.-Distance from foundation___f _ ------Distance to nearest lot le____S_______ <br /> p Number of lines___'I------_------__________---Length of each line---------&' Width of trench--- ____------A---------- <br /> Type of filter materialf a'4!.Rdk Dep+h of filter material______ fi-. Total length___Arae ____________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------_Distance to nearest lot line_,___-__--______ <br /> ❑ Number of pits----------`------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- Lp`1 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__-_-_-_----_______-_________________ <br /> ❑ Size: Diameter------------------------- ------------Depth............................ ------------------------Liquid Capacity----------------------------gals. 1 , <br /> Privy: Distance from nearest well------------------------------------------------Distance from nearest building-----,_----------------------------------- <br /> Distance <br /> __________________________ -_----- <br /> Distanceto nearest lot line---------------------------------------------------------------------- --------------------------------- ------------------------------------ <br /> Remodelingand/or repairing (describe):------------ ----=`----------------------------•---•------------------------------------------------------------------------------------------------ <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 .Count <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> )S ` � ___Owner and/or Contractor <br /> Egned ---------- <br /> By:------------------------------------------------------------------------- ---------------------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot <br /> --------- ----------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., .can be placed on reverse sidg). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY----------------------------------- ------------------------------------------------------------ DATE----------- ----- <br /> REVIEWEDBY----------------------------------------------------- ----------------------------------------------------------- DATE----------- - ----------.------------------------------ <br /> BUILDING PERMIT ISSUED--------------------- -- - - - - -- --------------------------------------------------------- DATE- <br /> __---- __ _______________________________ ______ ------------------------------------------------------ <br /> --------------------------------------------------- <br /> Alterations and/or recommendations:_�, •k AS------------------------------------------ <br /> ------------------------------------------------------- ---------------------------------------------------------- ------- <br /> ------------ <br /> FINALINSPECTION BY----------------------------------------------------------------- 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 , Revisea 1.57 F.P,CO. <br /> T_ <br />