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APPLICATION FOR SANITATION PERMIT <br /> t (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 /> JOB ADDRESS AND LOCATION_ tA-----___- _ _ -_----�;-;___-.------I '- -------- ----------------- <br /> -----/ __- / <br /> / ----- .----_----- -�11-.�/~.tel <br /> Owner's Name-------------- _i_N ' ! Y_.-/=E i <br /> x . ------ ------- --•- --- -1--- a <br /> Phone � _ _� <br /> Address_____. .. <br /> ------------------ <br /> - ------ --- <br /> Contractor's Name - `-` ' 'r' - ` -1 �� ��`1�/�/�� Phone__C��_ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f <br /> / <br /> � <br /> Number of living units: ❑ Number of bedrooms 0" Number of baths 1❑�.pLot size---- f__________/.___._: _--- -------- <br /> r irk- <br /> Water Supply: Public system E] Community system ❑s Private ©,, <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay E] Adobe 0 Hardpan ❑ M <br /> t 1 <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 <br /> _________________________-_-_ <br /> No. of compartments------ ---- __Capacity _______Size________________________________Liquid depth-------------------- <br /> Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material-------------------------------------. <br /> ❑ Size: Diameter--------------------------------------Dept h---,'---------------------------------------------- <br /> Privy: Distance from nearest well__________________________________ _____________Distance from nearest building------------------------------------------ <br /> F-1 Distance to nearest lot line--------------------------------------__________ <br /> if 4 <br /> r _ <br /> P,g z -- --.� _-_ Distance to nearest lot line_ _.___:_�_ <br /> Seepage e Pit: Distance to nearest well -��n, Distance from foundation__-< ___ <br /> Number of pits___�:A_C_____Lining material /v-__-H �_-Size: Diameter_x__�-_r_'_____-___-__`_-Depth_Z_l__+ <br /> -----•------------- <br /> Disposal-Field: . .-Distance from nearest,well________________.Distance from-:foundation_:==- Distance+to-nearest lot-line__-_ <br /> ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench--------•------------- ------ <br /> Type of filter material-------------------------Depth ofjilter'material---------*___________- <br /> Remodeling and/or repairing (describe):-_-_____ _ �# '--_-- -__!'- krt _f~ / <br /> . -------------------------------- <br /> --------------------------------- ---------------------------='"�------------------�-----•--•=----------------- = '-------- -------= -------------------------------------------- <br /> -... <br /> ---------------•--- •--------------=--------=�'`�------'`------�-�,���------------""'�------ -•---�`-"-f 1'� ----------------•---------------- - <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State.-laws, and rules and,,regulations of the San Joaquin,Local Health District. <br /> (Signed)..._.. =_ '` T-J"* �--�-` /-�- - ` �rCs _ -___-.---(Owner and/or Contractor) <br /> By:........ <br /> `t 'f f fa �= (Title) r-:' r'` . <br /> ----------=----- -------- <br /> r <br /> (Plot plans, showing size of lot, location of system in relation to Wells,'ibuildings, etc., must be fled with this application). <br /> FOR DEPARTMENT USE ONLY <br /> T� <br /> APPLICATION ACCEPTED BY------------------------ - --------------------------------- ------ DATE---=--------- +r ff <br /> REVIEWED BY - '=:-+------------------------------------------- DATE---- --------------�- oLr <br /> ----------' <br /> BUILDING-PERMIT ISSUED--------------------------------------------------------------------------------------=-------------- DATE <br /> ------------- <br /> Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- <br /> --------•- ---------------------------------------------•-----------------------------------------------------------------------------------------------------------------------------------------------. <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------•-•---------------------•----------- ----- ------------- <br /> --------------------------------------I---------------------------------------------------------------------------------------------------------------------------------- <br /> -------•---------------------------------------------------------------------------------------------------------------------------•-----------------------_------------------------ - ---------- ---w; <br /> PERMIT N1.__1j------------ ISSUED__--__�`!- I-ISI------------(Date) FINAL INSPECTION BY:------------- -- --- --- ----- <br /> ------------------ <br /> j <br /> -. <br /> Date------------------------- yZ'- - L f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 , <br />