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Y <br /> APPLICATION FOR SANITATION PERMIT Permit No.//.�(._�-- <br /> (Complete in Duplicate) Date Issued <br /> F ,3_.{Q- <br /> 13 {9/5-3 <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 Orddina ce No. 549. ----- <br /> _ . __I <br /> JOB ADDRESS AND LOCATION----------- - - -- -- -- --- ---- -------------- - 6_'.------------------------------- <br /> Owner's Name----------------------------------------- 9-t---- - ' ------------------ - --- ------------- -------------- ------ Phone--- ------- <br /> Address. <br /> --------------------------------- ----------- lm----------- --------------- ---------------------------------------------------------------------------- <br /> ,Z7 <br /> Contractor's Name--------------------------------- ------------------------------------------------------------------ Phone--------9-----f-4-,P-7---- <br /> Installation will serve: Residence � Apartment House E] Commercial [] Trailer Court F] Motel El Other El <br /> Number of living units: A Number of bedrooms _V Number of baths Lot size ---------------- S-0 <br /> ---/____ - ----------------------------- <br /> Water Supply: Public system F-1 Community system ❑ PrivateDepth to Water TabIej_i0ft.*— <br /> Character of soil to a depth of 3 feet: Sand El Gravel El Sandy Loam E] ClAdobe X Hardpan E] <br /> Previous Application Made: Yes E] No K_ New Construction: Yes E] No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> No.septic tank or cesspool permitted if public sewer is available within 200 feet.} <br /> Distance from nearest well_________________Distance from foundation__-.---_-_-_- Material-__------------- --------------------------- <br /> A.—I No. of compartments-- ------- ---------_----Size----_--------------------- ---Liquid depth--------------------------Capacity------------------­---N <br /> Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line--_------------- <br /> of Number 1 lines-----------------------------------Length of each line-----------------------------.Width of french----------------------------------- <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length___-__________________--________________-_ <br /> 10.0-or <br /> Seepage Pit: Distance to nearest well-- Distance fr foinciation--/..6'.-'----.Di§,tante to nearest lot line------1-9-- <br /> Number of pits.....I---------------Lining maferiaI_C_'C1&_ Size: Diameter---, --,,2--- ----Depfk__P__0 /--------------- <br /> Cesspool: Distance from nearest weff-----------------Distance from fou,ndafion--------------------Lining material-__-____-________________-______. <br /> Size: Diameter--------------------------------------Depth---------------------------------------------------Uquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--- _-_- ---------------------------------------Distance from nearest building--------------------_.-_______-__-------_. <br /> ❑ <br /> uilding---------------------------------- ------- <br /> El Distance to nearest lot line-------------------------------•-- -------------------------------------------------- ------------------------------------- ------------ <br /> Remodeling and/or repairing (describe]:------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------I----------------- -----------1------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------ <br /> I hereby <e_rfiN that I ave pre ared this application and that the I ork will be done in accordance with San Joaquin County <br /> ordinances, St fe [a S, an frules an regulations of�e San Joaquin cal Health District. <br /> ----------- --------- - s-ACI-111--------_1_1------- <br /> ---- --- ----------------------- ------------ ---- Qwnetma#tor Contractor) <br /> By:--- ---------------------- - -- - ------- I)__4A �--------------(Title) ---------------- <br /> (Signed) <br /> (Plot plan, showing size of lot, location of system'in lation to wells, buil 1)ngs, etc., can be ga�c3ed on reverse side). <br /> re <br /> f Wel a an Pa n <br /> j <br /> ri FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED,BY__________________________ -----------------— ----------------------------------------- DATE------------- <br /> DATE------------ -V� -- A ----- <br /> REVIEWEDBY-------------------------6,------------------------- ---------------­-------------------------------------------------- DATE- ----- ----------- ----------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------- ------------------------------------------------------------------- DATE------ ------------------------------------------------------ <br /> Alterationsand/or recommendafions:------------ ------------------- ------------------------------------------------------------------------------------------- ------------------------------ <br /> ---------------------------------- ------------------------------------------------------------------------------------------w------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ <br /> --------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- <br /> ------------------------------------- -------------4---- ------------------------------------------------------------------- ---- -------------------------------------------- ------------- <br /> FINAL INSPECTION 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 /> E5-9-2M 10-52 Revised W-2100 <br /> Jam- <br />