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Lt ko; <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> -t (Complete in Duplicate) <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein de <br /> This application is made in compliance with C ty Ordinance No. 549. t <br /> JOB ADDRESS A OCAT - <br /> Owner's Name - <br /> Phone_--------------------------------- <br /> Address..... - a-`--�--` -- ---- ------- - - --------------- <br /> '-- t � ------------------------------------ - <br /> - ----- <br /> -----------------------------­------------------ <br /> Contractors <br /> --- --- <br /> Contractors Name- �---- ---=���------•------------------------------------- Phone-QG7 ---- <br /> Installation will serve: ResidencetA'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __/.__ Number of bedrooms ___�__ Number of baths J--_ Lot size ------�4e_*!� -------------------- <br /> Water Supply: Public system ❑ Community system❑ Private Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adoberj6,_Hardpan <br /> Previous Application Made: Yes ❑ No' New Construction: Yes 34 ❑ FHA/VA: Yes ❑ No ❑ <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 Dista ce from unjation__ .Q__�_.--____.M terial �__ --. ------ <br /> ------------ <br /> _ _. <br /> of compartments----_ __-__-f--__Size_ _-._._Liquid depth____��!_-_-__Capacity. ---------- <br /> No.Dis sal Field: Distance from nearest well-1-1130--t--- Distance from foundati -Ib--._--__•_.Distance to nearest lot line....a�_-..... <br /> [� Number of lines-----]/___1�__ _,__,_____ __-_-_-Length of each line----- _� -----------Width of trench-_-4:--- ----------- <br /> Type of filter material.. ------Depth of filter material-----/-f"-------Total length---------- Q- -------------••_-__ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- <br /> ElNumber of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------__---_ <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 /> Remodeling and/or repairing (describe):-----------------------------------------------------------------------------------------------------------------------------------------•-------- <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, to laws, and rules and regulations of the Loc Health District. <br /> (S'9 -------------------�----------'-�-�-�-�'-�------------- ---- --- ----- ------ -----•--------`----------------------....------------( Contractor) <br /> i7ply----------------------------------------------------------------------------- =---- - --- - - ----------------------------(Title)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in ela to wells, bui rags, etc., can be placed on reverse side). ' <br /> tOeDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- fi_sx- _-_• ______________ DATE__-_---__ z -- <br /> REVIEWEDBY------------------------------------------------------------------------------ ----------------------------------------- DATE------------ <br /> ------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations------------------------------------------------- -------------------------------------------------------------------------------------• __------------ <br /> ----------•------------------------------------------------------------------------------------------------------------------------------------•-------- --------•---------------- --------------•---- ------ --------- <br /> ----------------------------------------------------------------------- ------ - -- ---- ------------------------- ------------­------- ........ <br /> FINAL INSPECTION' BY----------------------------- r~ Cd <br /> - Date----------- - <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 Revised 1.57 F.P.CO. <br />