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S3 „' <br /> APPLICATION FOR SANITATION PERMIT Permit No. V_ <br /> .y� �..r <br /> 1y� (Complete in Duplicate] <br /> Date Issued <br /> Applica+ion 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 LO ATION___-"_"" -------------:---" -- " . <br /> a t <br /> Owner's Name - --- -- ----- --------'--------------------- Phone-------------------------1 --------- <br /> "" <br /> Address----------------- -. -s ------------------------........---•------------------ -----------------••--••--•L------------ <br /> Contractor's Name -------------------------------------------- Phone._ Q.!........L7-------- <br /> 3 e <br /> Installation will serve: Residence_ .f <br /> Apartment Hdiise' Commercial E] Trail er Court E] Motel E] Other E]Number of living units: . <br /> __ Number of bedrooms _"� Number of baths """" _ Lot size ___.__ _ �-_�_.---'--------------------------------- <br /> Water Supply: Public system ❑_#Community system""-[] Private;K Depth to Water Table/—f+, <br /> Character of soil to a depth of 3 feet:! Sand E]Sand Loam ElClay Loam ElClay E] Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes No ❑ I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool-permitted if public sewer is available within 200 feet.} i <br /> Septic Tank: Distance from,nearest welLa�__, :Distance�frorp foundafion-J11 A -l.--`__-Material_-- "--" _ ------- <br /> No. of compartments- ..-.a�-.- Size_���4tf AS .. <br /> AS Liquid depth--.-" -fir-___.__Capacity.___ <br /> Disposal Field: Distance from nearest welt"/a.6*-....Distance from foundation------ ''..__.Distance to nearest lot line__e sr.__�.... <br /> g , <br /> Number of lines-------------1---��'--:-� //-�------Length of .line---------d--- °------ Width of trench-- - -�--.---------------- <br /> ° Type of filter material._S.__[ --""Depth of filter material----/ "-��"=""-"-To+al length-__-_- - "�"------------------------- <br /> SeepagePit. Distance to nearest well____.__.__..._._____- ---Distance from foundat�an-_ti.""""-""___"."_".Distance to nearest lot line.-"_-:"""""""""_ <br /> ElNumber of pits----------------'------Lining,material-- ---°---------------.Size:Diameter---- --------_------- Depth-------------------:.------------ <br /> Cesspool: r Distance from nearest weld"..........,._-_Distance from-foundafion_{_J.:-.--------'Lining material--------------------._._-.-_-------- <br /> ❑ Size. Mameter----------------- --------- -:-------- _- <br /> Depth-----------.--- _ - : <br /> -- --,----- - ----- -----------Liquid Capacity_--------------------------gals. <br /> Privy:' Distance from nearest well------------ . ....... Distance from nearest building--------------------------_. ---------- <br /> ❑ Distance to nearest lot line---------M ----------------------- �. ------- •--. --------- <br /> Remodeling and/or repairing(describe]:----_-----"-_-. ` <br /> t . <br /> ---•---•--•-----------------•---------------- <br /> --------------•---------------------------------------=----------------------------------•-------------------------------------------------------------------------------•-------------------------------------------------- <br /> f f t <br /> --------------------------------------------------- ----•------------------------------------------ ------•--•------------------------------------------------ <br /> f I—.------ -- <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, Sta a ws, and rules and regulations of the San Joaquin Local Health District. <br /> V ' <br /> � �' �'�-- I�--�' a r---------- - --- weer and/or Contractor) <br /> (Signed)------ ----- <br /> By:-------- � � - --- ------------------------------ ---------------(Title) = "" <br /> `�-�� <br /> (Plot plan, showing size of lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- ----------------- -------------------- = --------.- DATE------------..� _.�.. �' � <br /> ------ <br /> REVIEWEDBY------------------------------------ ------------------------------------:---------------------------------- DATE------------------------------- --------------------------- <br /> BUILDING PERMIT ISSUED--------------------1--------__ ` <br /> ' ---------=------------------------------------------------------------ DATE-, ----- ------- ------------------�------------------------ <br /> Alterationsand/or recommendations------------------------------------------------------------ ----------------------------=------------••------------------"•--------•------------------------- <br /> -------------------------------------- ----------------------------•--------•------------------------------- --------------._.------------------------------------------------------------------------------------------------ <br /> --------------------------------------------------------------------------------- ---------------------------:;-----------------------=--------_--....'_----•---• ------------•---------- ... --------- <br /> 4 <br /> -------------------------------------------------------- ------------'---...-------------------------------------------------------------- -----------------..-._-..- --- -----.._.--------_------------ <br /> FINAL INSPECTION BY:- F=" `-------------------------------------------------- . _ Date--/.---------------- - -----:7----- ------__.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street - 014 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; . Revised W-2160 <br />