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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued T)-------/- <br /> Applica4-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 /> S C) iF <br /> JOB ADDRESS AND LOCATION_-.._-- ------------------------ <br /> -------------------------------------------------------:-------------------------------------- <br /> ------------------- - -- -------- <br /> Owner's Name----------------- ut ----------- ------- --- ---- Phone <br /> Address..---------------------------i...... S,�y -4-,# <br /> ----------------------------�­------------------------- --------------------------------------------- ------- <br /> ---- - ----- -- <br /> Contractor's Name____________________________ <br /> "' <br /> -------- -------------------------- ----------------­ ------------------- Phone L <br /> ---------------- <br /> Installation will serve: ResidenceApartment House [] Commercial 0 Trailer Court urt [__1 Motel El Other E] <br /> Number of.living units: -------- Number of bedrooms _.I___- Number of baths -------- Lot size <br /> Wafer Supply: .'Public sys'+4�n A Community system El Private El Depth to WateP Table -------- ft. <br /> Character of soil to a depth of i fe'e't:' Sand-C] Grove] D- Sandy Loam E] Clay Loam E] Clay El AclobeilQ/ Hardpan ❑ <br /> Previous Application Made: Yes E]. No �, New Construction: Yes> No ❑ <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--------------------Iv1 a ferial <br /> 0 No. of compartments-_----------------- ----Size----_-------------------------Liquid depth--------------------- ---Capacity----------------------- <br /> Disposal Field: Distance from nearestwell.................Distance from foundation-------------------Distance to nearest lot line----------I------ <br /> ❑ Number of lines-----------------------------------Length of each line-------•--------------1-_-----Width of trench <br /> Type of filter material-------------- ---------Depth of filter material-----------------------Total- length------------------------------------------ <br /> Seepage Pit: Distance to nearest well_____________"______-Distance'from foundation--------------_----Di:�sf�a`n_cE�'fo nearest lot line----------------- <br /> El Number of pits----------------------Lining material--•--------------------Size: Diameter------------------------Depth-------------- <br /> Cesspool: Distance from nearest well-'r----.--Distance fromfoundation....1:0........ Lining material- rek uT, <br /> r ----- -------- --- <br /> Size: Diameter.-_... ----------Depfh___,:�7---(&--------------- ---------" --Li cluid Capacity. --------------------------gals. <br /> Dista-rice from'nearest well-------------------------------------- ---------.-Distance from n"ea-r-est--b-uildi-n'goft--'-i�-�----------------------------- <br /> El Distance to nearest lot lire-------- ------- -------- ------------------ <br /> -a <br /> -------------------------- <br /> ----------------- .. <br /> Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------- ------ <br /> ------------ <br /> -------------------------------------------------------------------------------------------------------------------------­­--------------------I------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------I----------------------------------------------------------------------------------------------------- <br /> I ----------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------- ----------------------------------------I--------------------------------------------------------- <br /> --------------- <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, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed R/ # �on_ <br /> ------ ----- ----------I------ (Owner and/or Contractor) <br /> 47"" <br /> ---------- ----------------------------- ------------- -------- <br /> By------------------------------------------------------------------------------------------------------------------------------._{Title)-- -------------------------------------------------I------------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY T <br /> APPLICATION ACCEPTED BY..-..'f <br /> - - --------------------------------------------------------------- DATE---- -- I <br /> -------------------------- ---q114 <br /> REVIEWED BY--------- -------------- ----------------------------------------------- DATE----- <br /> ' -4-----I- -------------------- <br /> BUILDING PERMIT ISSUED-_-------- ---------j)ATE_____--------- <br /> Alions and/or recomm dation <br /> s:--- <br /> --- ----- - - ------------- ---- -------------------- <br /> - -V -C - t .. ----------------- <br /> -----------I------------I--------------1,............... -- --------------f --a------------------------ -- ---- <br /> A_1A —Aa ------:?_­ ---------------------------------------------------------------- <br /> -------------20-el, - ------------ <br /> /.2— ------ - - ----- <br /> FINAL INSPECTION BY:----= Date--- - <br /> . <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 /> ES-9-2M 14 ATWOOD 1254 <br />