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'J APPLICATION FOR SANITATION PERMIT Permit No.-,.?.l__7__v___ <br /> ,i /,4Idvl (Complete in Duplicate) <br /> Date Issued/-- -- --S. '- <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 /> -_ <br /> JOB ADDRESS AND LOCATIONo- <br /> - _ <br /> -- ------- --- "" <br /> Owner's Name ! -- ------------------------------------------------ <br /> ------------------------- <br /> - <br /> Address------0 .1 - Mi -----�' <br /> - - -- -- -- ----------- ---•-- .......... <br /> Contractor's Name__A.�t-----� - _a -- - -, <br /> - o-.__ Phone__ "'_ ° i <br /> ------------- ----------- f <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 <br /> Number of living units: ! _- Number of bedrooms ..2-_ Number of baths __ -_ Lot size <br /> ------------ <br /> Water Supply: Public system Community system '❑ Private 0 Depth to Water Table _ffa ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobejK Hardpan ❑ <br /> Previous Application Made: Yes ❑ No W New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: LMQ <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--- d`. rk-�-------- --- <br /> No. of compartments----------.2------------Size_ _.3G�•�'P Liquid depth__-__4............Capacity <br /> ___• Ql -_--_-- <br /> Disposal Field: Distance from nearest wEfh.�--Distance from foundation____/$"_' ____.Distance to nearest lot line_ .R_ <br /> Number of lines-----------/---------------------Length of each line--___V_1 ---1------------Width of trench_--- _ -"------- __------ <br /> Type of filter material.`;f"­_/ft,----Depth of.filter material------AP__-'_"_____Total length_- _:_'. 'd --"" <br /> Seepage Pit: Distance.to nearest well- x '__Distance from foundation-----SO----_Distance to nearest lot line---/0....__ <br /> Number of its____.___ imaterial___---, - rze: Diameter____________Depth_____.. __---_______________ <br /> �• PLining <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material______-___:_______-_--________-____-. <br /> ❑ Size: Diameter----- -------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well ____________------------------------------------Distance from nearest building------______________--__________________. <br /> ❑ Distance to nearest lot line <br /> Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------•--•---------------------------- ----------------•-----------••-------------•---------------•------------------------•-------------------------------------- --------------------------------- <br /> ----------------------­------------------------------------­-----------------------•-------------------------------------------------------------------------------------------------------------------------------------- <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)...... pm_" <br /> BY:----- ------------------------------------ <br /> --=•-- --->� _ �_ ;-�-- � r Contractor) <br /> or) <br /> ------------------- --------------------------------------------(Title) - 16� ----------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- --------------------------------------------------------------- DATE- <br /> REVIEWED BY ------------- DATE- ` <br /> BUILDING PERMIT ISSUED ----------------------------------------------------- ---------------- DATE-----------Q! <br /> ------------------------------ <br /> Alterations and/or recommendations: ------------------------------------------------------ ----------------------------- -------------------------------------- <br /> ----------------------------•---------------------------------------------------------------------------------------------•----------- ----------------------------------------------------------------------- <br /> ------------------- -------------------------I---------------------------------------------------------- ----------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:_ ------ ' t��� ____------------ Date------ <br /> r <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 BSI Revised W-2€00 <br />