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APPLICATION FOR SANITATION PERMIT Permit No. ...... <br /> 1.. '3__ <br /> [Complete in Duplicate <br /> r � -fir ...� .. }• pate Issued ._- _!���__ <br /> i <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 Count Ordinance No. 549. <br /> JOB ADDRESS ANp LOCATION- / '� r ______------ <br /> Owner's Name. , ----- ------- Phone------------------------------------ <br /> Address-------------- �••• r --------- ` �- ¢�_ .,¢�: sem: ----- - ------------------------- •--------•--... -------••--•. <br /> �{ , <br /> . r _ -�---- ----------------------------------------------------------------------------------------- PhoneWW�??��I ------- <br /> Contractor's Name..___ <br /> Installation will se ve:�fResiclence Apartment House ❑ Commercial E] Trailer Coin ❑ Motel ❑ Other ❑ <br /> i* s•-� - <br /> Number of living unit ! umber of bedrooms __r� Number of baths __/_. Lot size _______________ _- d____________________ <br /> l; <br /> f <br /> Water Supply: Public",s s,teni' [] Community system ❑ PrivateX Depth to Water Table/-�'�ft. <br /> WI �ow .� <br /> Character of soil to a depth�of 3 feet: Sand E] Gravel E] Sandy Loam El Clay Loam Ej Clay El ' Hardpan ❑ <br /> Previous Application'Made: Yes ❑ No New Const.ruetionx,,,.Yes_g.No_x <br /> i <br /> TYPE OF INSTALLATION AND SPECIE CATIONS: <br /> {No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` <br /> p -----;•- �-Size--�---�3�;.-------.Liquid de th_.Mate�al---��°-------------------------'--------' <br /> Septic Tank: Distance from nearest well___-4/4______D'€stance froejo:undation_____ _ d_ <br /> No. of co'mpartments__•---o� q N p �___ ,1�__.____Capacity__.___ ------- <br /> s <br /> , <br /> Disposal Field: Distance from nearest wel�__ _�' ._.Distance from foundation__��.__-_ _.Distance to nearest lot line____. -•__- <br /> Number of lines______ _____________ _____ __Length of each line____!_a4__�k------_.Width of trench.___ __j� <br /> Type of filter material,_--5___e -_Depth of filter material----- "-__-Total length_____ ................::________- <br /> Seepage Pit: Distance to nearest well__________________�__.D.istance_from_foundat.ion.:__'::.- _.... ..Distance to nearest lot line-------­-------- <br /> El Number of pits---- ---------------Lining material------------------------Size: Diameter_--------------------Depth--------------------------------- <br /> Cesspool: <br /> Distance .from nearest well--______.e=____ <br /> Distance from foundation___--------------___Lining`material___________._______________-________. <br /> ❑ Size: Diameter----9:--------------------- - rbepth---------;--------------------------------------__.Liquid Capacity-----------------------------gals. <br /> Privy: Distance From nearest well-------- M1 ----------------------- ---Distance from nearest building------------------------------------_-'--' <br /> ❑ --=-------- -------­---------------------------------------------------------- <br /> "� Distance to nearest.'lot line______,__ ` - ^' '*"` { <br /> Remodeling and/or r airingd{describe :____�?�.__ �� ___{ - �! �_, ,-r_ _ ___. _ _ ,�. .�..h; .___... <br /> •----------•-------- :------•--•----•-----•----------------------------------------- - -------------------------- ---------------------••-------- <br /> -------•------------------------------------------------------•---9F-----------------------------•------------•----------------------•--------•--------------------------------•-------•--------•--•-----•--------------"---------- <br /> '. -I <br /> - ------------------•-- -- ---------------------;------------- _ - <br /> i, r• <br /> I hereby certify that I have prepared this application and"+hat the work will be done inlaccordance with San Joaquin County <br /> ordinances, StA laws, and rules and regulations of the San Joaquin Local Health District. <br /> �- Owner and/or Contractor <br /> (Signed)----------- -- ------- ------.------ -----' ----- -•---------------- ------ --N ------- ) <br /> By:. <br /> - s'- I Tale <br /> ..P.rt' �,...�. - ----- ----- ----{ )--------------------------------------------- ------------------ <br /> (Plot <br /> ------ --------- I <br /> (Plot plan, showing size of lot; location ofsystem,i efe+ion to .glis, buildings,,etc, can-,be laced on reverse side). <br /> FOR DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY >--••.> - = .D.ATE----------------------------------- ----------------------- <br /> REVIEWED BY � i - - --------------------- DATE-----------� <br /> BUILDING PERMIT ISSUED ------------------------- DATE.----------- _ .. . f p, <br /> Alterations and/or recommendations: ------------------------------•----•- ---•------------•----=---------------------- ------------------------•-------------------- <br /> ----------------------••----------------------=---------------•-----------------------------------------•-•-------------------•--•----•------------••--•-••••-----••--------------•---•-•......---•-----------•----------- <br /> ----------'---------------------------------------=---•------------------------------------------------------------------------------------------------------------------------••-----------------------------•--------------- <br /> ,u,., <br /> ---------------------------------------------•--------•--�;•.----------x -----'----------I---------------- ------------------------------------•---------------------•-•----------------------------------•-•--•--------- <br /> ,- - ------•---•------------------------------------------ ----------------------•- <br /> - - <br /> * r �17 <br /> FINAL INSPECTION BY:.---"---- ------- --- - ------------ --=---------- -------- Date---------------- . <br /> SAN'JOAOUIN 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 /> F�S-9-2M Revised W-2100 <br />