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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) pate Issued ._ _ .y_ S� <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 ANDTION..._ ._ M = _ <br /> Owner's Name----- ------ --------- � il � ------ .........--------------------------- Phone-------------------------- <br /> Address------------- ------� -- .. •--------- <br /> ---I ------- -------------------- -r— <br /> Contractor's Name.. .�! �_'_ -- { ------------------------------------------ one--- -- ------------------ <br /> Installation will serve: Residence Apar ent House ❑ Commercial ❑ Trailer Court ❑ Motel Q Other <br /> Number of living units: j Number of bedrooms Number of baths ."'`' Lot size __ <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Wa er able _to_ "t. � <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Mader Yes ❑ No ;New Construction: Yes E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> ❑ teINo septic tank or cesspool Permitted if public sewer is available witiii"20 a <br /> tio __Septic Tank: Distance from nearest well-----------------Distance from founda __._--_ <br /> ___-_.Material-__--_-_.-._-__-----_-_-_._--•. <br /> No. <br /> a <br /> of compartments--------------------------Size------------.-------- <br /> -----------Liquid depth--------------------------CapacitY----------------------- <br /> Disposal Field: Distance from nearest weEl--------.----..---_Distance from foundation.___"':`_-:-.- -.Distance to nearest lot line----------------- <br /> ., __ � _ .,....Y.. <br /> [] Number of lines-----------------------------------Length of each line_:-----------------------------Width of trench----------------------------------- <br /> Type of:filter material-------- n_..Depth of filter material--------------........Total length----.-----------_.__.___._---__----:._ <br /> Seepage Pit: Distance to nearest well_. _--.-.---.__Distance from foundatio ----./_Q-------,Distance to nearest lot line--. . <br /> Number of pits.........----------Lining material Di er___"7F''X&.___Depth....___ <br /> - ---------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material__-__--------- -----._._.---.___---_ <br /> Size: Diameter.--.-_._.--.-"-------.-_---�---�---.--,-- --.--_----;,.De _A...,--�------.-----.-_-�-�--�--.---.-.-------------- -.:----.-- ----- Liquid- Ca ac-it -- _----------.-gals._. <br /> -moi <br /> Privy: Distance `rom nearest well_____________ ___________________________________Distance from nearest building.---_.-.--.-_.---_----_-----------_-__--_. <br /> ❑ Distance to nearest lot line--------t------------- ------- ------+-----------•---------------------------------------•-------------------------------------------------- <br /> �.t�t 1 ' - <br /> Remodeling and/or repairing (describe):--------- �-- --�-----f-i---- --- -----------------••--- ------------------------------I---------- --------------------- ------------------ <br /> -----------•---•---•-------------•-----------------•--------- -----------•--------------------------•----------------•---•-••-•----------------------------------------------------------------------------- <br /> -----------------------•--------------••----=-------------.-_.------•--••-•----- •-----------------•-----•-----------------------------...----•------•--------•-•--------------------•------•--•--------••----------- <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 /> y <br /> (Signed ' (Owner and/or Contractor) <br /> By:..... -------------••---•--------------------------------------------r----------------------------------------------(Title)--- -- ---------------------------------------- ------ <br /> t "(Plot plan,-showing-size-of,lot,7location-of-system-in-relation to-wells,-buildings,.etc.,-can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------------------- ----------- ---------------------------------------------. DATE-------------------------- <br /> REVIEWED BY--------------------- DATE--------- .. <br /> BUILDINGPERMIT ISSUED------------------------------------ DATE---- ------------------------------------------------------ <br /> Alterations and/or recommendations:..............._ <br /> 4"------I----- - ----------------------------------------------I--------------------------------- ---­----------­--- ----­--------- <br /> ------------------ ---------------------------=--------------------------------------------------------- ----------------------------------------------- •-----•---------------------------------------------------- -------- <br /> ------ ---------------- ------- -------- --------- ------------------------------------------ ------- -----------------------------------------------------------•----- <br /> FINAL INSPECTION BY:. Date------- _'. ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5--9-ZM 145446 ATWOOO 12-54 <br />