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-� 0 <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <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 /> --------- ---------- <br /> JOB ADDRESS AND LOCATION -------------------------------------------------------------- ---- ----------- � -- <br /> Owner's Name `--r------------ - � l'S------------------------- ------------------- Phone----R`��--F_3------- <br /> ------------------------------ - - <br /> Address-------------------------------- �-- Ca -----------------------------------------•--------------------------------------- <br /> ------ -------- <br /> AD _ 45— . <br /> Contractor's Name--------------------------------- - --------------------.----------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence [Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑, Other ❑ <br /> Number of living units: Number of bedrooms [:. Number of baths Vf Lot size--------- ____________________ <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ „ <br /> Character of soil to a depth of 3 feet-. Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <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____ -0-!!vo a_ __jl___-__. <br /> ZNo. of compartments_.________�_________-_Cap ---Size-_�4o__��-......Liquid depth________ _ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------_____-- <br /> ❑ Size: Diameter--------------------------------------Depfh!------------------------------------------------- <br /> a - <br /> Privy: Distance from nearest well__________________`_-____'____________________Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line__________________` "'`-___________________ <br /> Seepage Pit: Distance to nearest well-----------------_-----Disfairce from foundation--------------------Distance to nearest lot line_--______________ <br /> ❑ Number of pits---------------------Lining material------------------------Size: Diameter------------------------Depth---------------------_------7--- <br /> Dispos I Field: Distance from nearest well________________Distance from foundafion___________,------Distance to nearest lot line___`r___-__ „ <br /> Number of lines_:______'__:_ ____��-,_Length of each line____________ a___�--___--Width of french--------__--_ ------------------- <br /> Type <br /> __ _________ <br /> 9.., /_ <br /> Type of filter material____C_Ak__-__;. -Depth of filter material____'- -_ _____ <br /> Remodelingand/or.repairing (describe):-------------------------------•------------------------------------------------------------------------------------------------------------------------- <br /> e - �, ► , <br /> ----------------------------------------------------------------------------'--------------•------------------------- c <br /> ------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- <br /> I herebycertify th ave prepared `+his application and that the work will be done in accordance with San Joaquin County <br /> ordinances to Ia�, d ules and° regulation of the San Joaquin Local Health District. <br /> a <br /> (Signed)------- �'--------- -- - -- --.----------------------------------------------------------------- --------------------------------------------(Owner and/or Contractor). <br /> By. ----------------------- --------------------------------------------------------------------------------------------------(Title)--------------------------------------------------- ------ <br /> (Plot plans, showing size of t+, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY____-_______ _ _____ ____ DATE----------- __� _ _ _ <br /> REVIEWED BY--------------------- �--� -- --------------------------------------------------- <br /> -------- 1 '---- -------------------------------------------------------------'DATE-------- ------------------- <br /> BUILDINGPERMIT ISSUED-----•----------------------------------------------------------------------------------------------- DATE----------------------- <br /> Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------- ------------------------------------------------- <br /> d - --------- / :v /'-- __ ala '�r�' --- e, w r�'� � -- ------- <br /> --------------------------- ...... -- s �rw[-----___F',lc.......... ...... ... ------ -----------------r------------ <br /> ---------------------I---------------------------------------------------------- ------- ----- _/__r � <br /> PERMIT No. `3�-'3------- ISSUED•----�--------------------------------(Date) FINAL INSPECTION BY:------? ------------------------------------------- <br /> Date----------- <br /> ------------------------------------------ <br /> Date.-•-------- ----------------------------------- <br /> SAN <br /> ------------------------ - -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />