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n� APPLICATION FOR SANITATION PERMIT Permit Nirjein <br /> j �'' ' (Complete in Quplicate) Date Issu ........ .Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work described. <br /> This application is made in compliance with County Ordinanc No. 549. <br /> s <br /> Q.�.. ...... �V�.- ..............�.... <br /> JOB ADDRESS AND LOCATION <br /> Owner's Name..... ............................... •- ........................ ......... -•-•-- ........................ P <br /> hone...� <br /> .. f ---•.................Address....................... . 1 _ �Q <br /> Contractor's Name---------------------------------'aw.ta.L.... .....=.................................................. Phone... =.�t?. ....... <br /> ._ .. <br /> Installation will serve: Residence Qf Apartment House ❑ Comrhorcial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 <br /> Number of living units: ./... Number of bedrooms .. Number of baths I... Lot siz© }�...f..6.4... .............•. S <br /> Water Supply: Public systet-IK Community system ❑ Private ❑ Depth to Water Table ' 40, ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ Q <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted'if public sewer is available within 200 feet.) ` <br /> Se tic Tank: Distance from nearest well.................Distance from.foundation....._.............Material..._._........._....-........................... V <br /> ®tA� 7 No. of compartments..---........ ............Size............................---Liquid depth........... ------.Capacity......................... <br /> osal Field: Distance from nearest well.................Distance from foundation....................Distance to nearest lot line---___--__..._-. <br /> RTZX~`__eNumber of lines...................................Length of each line'."....................Width of french....�............................. <br /> � Type of filter material.......:.................Depth of filter material.......................Total length--------- :..----.-.-----•--_---___-.._-- <br /> Seepage Pit: Distance to nearest well-..., .�.Q. .:...Distance f ��� I ation.t�P_'.-...DJ�-st ncg to nearest of line__-_./O._`_ <br /> �{ Number of pits...... .............Lining maferial..J�'�sd!f_ •ize: Diameter... ..>...........Deptn.. .n�....._.............. ' <br /> Cesspool: Distance from nearest well.................Distance from foundation . _. _;Lining materia(........:...................... <br /> ....... a <br /> ❑ Size: Diameter................. _ ...........Depth....................... <br /> ----•---------•-•------.....'Liquid Capacity............................gain. <br /> Privy: Distance from nearest well---------------------------------------'.....4-. Distance from nearest.building.!............. <br /> ❑ Distance to nearest lot line!.............�....:._...y......._.................-- -------•--._......_..... .'..._.. /... l <br /> Remodelinf`a'nd/orpre�pair�'ng (des ribe):......�', f(l0Aj.... i'_._ t-rc �.�5. .�._ ...__.._!�S! - :..' C?................ <br /> .. c .: .G2.a'. �w..i`'�.. "..4�ars�..+a�e.e re.orrm.... ---........ <br /> ----------- <br /> We: .......... ...... <br /> .... � <br /> .. <br /> I hereb certify thatil have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, �wj <br /> , and rules and re ulations of the San Joaquin Local Health District. <br /> r I <br /> (Signed)............. � •.......... ......................... ...... <br /> r Contractor( <br /> ---- Title ats/.... _.. <br /> (Plot plan, showing size of lot, location of system in rel n to wells, buildi s, etc., can be pla don reverse side). I <br /> FOR DEPARTMENT USE ONLY 4 <br /> APPLICATION ACCEPTED BY__. r.........-----.------.•--•----------....-.................................................. DATESN— <br /> .. <br /> REVIEWED BY............ <br /> ................ --- <br /> ....... ... :.......----• ---------...................................................... DATE... +��•-----•---•••-----.................... <br /> BUILDINGPERMIT ISSUED.............. .............•--..................................................................... DATE........ �'---------------------- <br /> Alterationsand/or recommendations:............................................................................................I................................................................. <br /> ..........................................................................................................................................•--•----••---.........---••--•-••--------•--------...--•---•-••--•-••--............. <br /> ...........................................................................................................•--•----•--•...............................:......................._........------•-•-..........._......................... <br /> s <br /> .................................. •..............._......................----•--•----•--.................................. -•..............---..........................-----....................--------......... i <br /> .............................................................................................................................• -....................................._................................................_..... <br /> FfNAL INSPECTION BY:------------- !CI. F ................... Date........ 7 5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 So'ufh American Street 300 West Oak Street 132 Sycamore Sheet $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> r <br /> ES-9-2M 10.52 Revised W-2100 y <br />