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APPLICATION FOR SANITATION PERMIT Permit No. -------------(- <br /> {Complete in Duplicate) / / r <br /> ti Date Issued ------/1 _ -- <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i <br /> This application is made in compliance with County Ordinance No. 549. + <br /> JOB ADDRESS AND LOCATION---------- '" --- ---------- ------- --- - -- - ----­--------­-....... •--------------------•-- <br /> Owner's Name----- ---- -- --- •---- - -- ------ -- ------------- --- ---------------- Phone------------------------------------ <br /> Address <br /> ----------------------- - - <br /> ------------------ -- -- --- <br /> Address-------------- ----f} -3.. -. --•- ------ —------ -- ---- r> --:r--Y------------------------------ --------------------- ................. <br /> C�/] -✓j •. Phone <br /> Contractor's Name- ....,. - <br /> Installation will serve: 'Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> ;�. Number of living units: . ____ Number of bedrooms __2--Number of baths Lot size _____�'7 ____j4 _ _____________________ <br /> Water Supply: Public system '[k Community system ❑ Private ❑ Depth to Water Table L-:Oft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay.Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No U�k New Construction: Yes ❑ No A <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 /> • of compartments--------------------------Size--------------------------------Liquid depth-------------------------- <br /> 10 <br /> Disposal Fie€d: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- <br /> r of lines-----------------------------------Length of each line----------------------,------.Width of trench----------------------------------- <br /> TY e of filter material--------------------------Depth of filter material-----------------------Total length-------------------------------•---------- <br /> ,---� <br /> Seepage Pit: Distance to nearest-well_.__/_V07i,[_Distance from fou dat4on-----__�G?.__......Distance fo nearest lot line.___________ � <br /> Humber of pits______=_____________Lining material__��-----� 'l i p al r----._ <br /> ameter Qe th. N <br /> Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material------------------------- <br /> .._-_-_______ m <br /> E] Size: Diameter--------------------------- -- -------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well......._------------------------------_----------Distance from nearest building____._..__---.-._-..._-_____-_.__._-.-_._. <br /> ❑ Distance to nearest lot line-------- ---------- ------------------------------------------------------------•----=-•----------------------------------•---- ----------- <br /> tr <br /> Remodeling and/or repairing (describe):---------------------- -----------------------------------•-----_-----------•---•---------------•---------------------...- <br /> :----------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------•---------------------------•--------------- <br /> - --------------------------------------------------------------•--------_....•---------------------------------------------- -------------------------------------• -------------------------------------------------------- <br /> --------------------------------•-----------•--•---•---------•-------•-----------•--••---------------------------------------------------------------------------------•--------------------------- ------ <br /> I herebrcerhat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, and rules and regulations of the San Joaquin Local Health District. <br /> -_.Owner and or(Signed) <br /> ) = (/� / Contractor) <br /> By: ! e c. ---------------- -----(Title)------ - ------ ------------------------------------ <br /> (Plot plan, showing size �Iocationf systemin 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 /> BUILDING PERMIT ISSUED---------------------------------- =----w-----------------------------------------•--------------- DATE--------------------Q------------------------------------- <br /> Alterations <br /> - -------------------------------- f <br /> Alterations and/or recommendations: ----------��-- ----------------------------------------------------------------------------------------- :-- <br /> -•-• -•---------------------- ----- -- ------ --- -- ----- - - --------------------------------------------------------•--------• --•-•----••-- <br /> -------------------------------------- --------------- --- ----- '�-- ---- � <br /> ---• -------- <br /> .1 <br /> ------ <br /> ------------------------------•--------------------- -- - ---------•--------------- ......------------- -•---•-----•---------------- -------- -•-------•-------------------------------•-------•---••-;-------------------- <br /> FINAL <br /> •- ------FINAL INSPECTION BY:.. Datef ._----- ..+ . <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 145446 ATWp 12-54 <br />