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•i <br /> APPLICATION FOR SANITATION PERMIT Permit No.ci7 ____________ <br /> (Complete in Duplicate) Date issuel �,5+� <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 /> JOB ADDRESS AND LOCATION_. - p-5-� ----- ------ - > ------------- ---- <br /> �G ` '�-------•---------------•---------------- <br /> Phone <br /> ------------- <br /> X <br /> Owner's Name------------­-----0 - --- , Phone <br /> -r-r -- <br /> Address----------•----------��­r-----JA� "e-------- ---'----------------------------------- <br /> Contractor's Name----------•----------- --- -------------------- Phone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> P <br /> .�:- . � �� ---------------------- <br /> -- <br /> Number-of iiving unitsu.rl_-_-Number of bedrooms .�___ Number of baths .-�_.. Lot size ____��_. _-- -- - ----------------------- <br /> Water Supply: Public-system ❑ Community system ❑ Private ® Depth to Water Table _ld-- ft. <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 DQ New Construction: Yes E] No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 fee , <br /> -----Distance from ------- Mate�al-- "" ----- --------- <br /> Septic Tank: Distance from nearest well _��- , found ion__ __ <br /> No. of compartments---------------------------5ize1D '-- X- __ cLiquid depth------3------.=--------Capacity--YW---------- <br /> Dispbsal Field: Distance from nearest well--s�d,-----.Distance from foundation)l__3?-____Distance to nearest lot e��_______. <br /> Number of lines---------�------- Length of each line-------- __-,�-------Width of trench-._.-r�_z-------- ------------•---� <br /> 11 <br /> Type of filter material_��---Depth of filter material___ --------.----Total length----------ig�-Q_------__-________--_X <br /> 11 <br /> Seepage Pit: Distance to nearest well__--------------------Distance from foundation__________..____-__.Distance to nearest lot line____________--___ <br /> Number of pits----------------------Lining material------•----------------Size: Diameter-----------------------.Depth---------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-__._.____.____----. ---------------- <br /> Lining material________.______._--_ <br /> .______.__._ Ct <br /> 46 =_-Liquid_Ca.paci.tY- _----=-__- _9aIs, <br /> r ❑ Sizer Diameter-------- -------=--------- ------Depth ------=-----------------_---------- ----- - <br /> } --------------------Distance from nearest bui{d'ing------------------------------=- <br /> Privy: Distance from nearest w1~II____.__._______._:______._._ -- <br /> ------- <br /> ❑ Distance to nearest lot line--- ------------------------------------ -------------------------------------------------------------------------------------- <br /> i <br /> Remodelingand/or repairing (describe):----------------------------------------------------------------------------- ----------------------------------------------------------------•------- <br /> _ -----------------------------------•----• •------------------------------------------- -------- <br /> ----------------- <br /> ------- <br /> ---- ------- --------- -------------------------•- r ----------- -------------------------------------------------------------------------------------------------------- ------------- - - <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, Wes, nd rules and regulations of the San Joaquin Local Health District. <br /> (Signed}___. (Owner and/or Contractor) <br /> --- <br /> ------------------ <br /> By:. = --- -- ------- - ----------- ----- ----- (Title) <br /> ------------------ ------------------ <br /> "(Plot plan, showing size of lot, location of system�in relation to wells, buildings, etc., can be placed on reverse side]. <br /> FOX.DERARTMENT U E ONLY <br /> APPLICATION ACCEPTED BY-"! - r_ ------ DATE--=- .-- -_--,Y ---. ------------------- <br /> REVIEWED BY------------------------------- - ----------------------------------------- <br /> --------------•---------------------• DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED----------------------------------------------- -------------------------------- ----------- DATE------ ------------------------------------------------------ <br /> Alteeationsand/or recommendations--------------------------------------------­---------------------------------------------------------------------------------.------------------------------ <br /> ---------- -------------------------- --------------- ---------------...----------------------------------------------------- -------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------•------ -------------------------------------------------------------------------------------------------------------- ------ <br /> ...> ------------------------------ <br /> FINAL INSPECTION BY--------- -- -- ------ --------------- bate f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> ' <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2140 <br />