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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> s <br /> 1 <br /> Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein"described: <br /> This application is made in compliance,with County Ordinance No. 549. a <br /> JOB ADDRESS AND LOC�ION �` 'T �AC, `� <br /> �� ��v �� <br /> Owner's Name----------------------------------- -------------------------------------------- - ------------------------------------------------ Phone----------------------------------- <br /> �—o ---------A-C' 5----- "/G `... � ---- --- <br /> Contractor's Name-------- ----------------- ------------- �----------------------------------------------- ----------------- Phone------------------------------------ 1 <br /> Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ J111 <br /> JPO ?` /C� c� 1 <br /> Number of living units: ©Number of bedrooms Number of baths E]./Lot size________ ---------------------+��l�., <br /> Water Supply: Public system [Community system ❑ Private ❑ ' <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Gay Loam ❑ Clay ❑ Adobe [✓Hardpan O <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 204.fe +, <br /> Septic ank: Distance from nearest well ______Distance from f undation__= __'___�Material____ T____________ <br /> �'' . <br /> No. of com artments____-_-_� _____Ca Capacity____________��Size__...._�__________�____ <br /> p p Y ---Liquid depth------ -------------------- I <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material________-___________________:____ �1 <br /> ❑ Size: Diameter-------'--------------------------------Depth------------------------------------------ <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------,._-_---_-__---- <br /> ❑ Distance to nearest lot line________________________________________________ <br /> .'Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__--_____________ <br /> ❑ Number•of pits`----q----------------Lining material----------------------.Size: Diameter-----------------------Depth------------------------- <br /> / r <br /> -- ------ <br /> ;.Disposal Field: Distance from_nearest.weEL Distance-from..foundation________ _____-__ -Distanceto <br /> -- e Length1lX-C'! <br /> ,�------ <br /> or <br /> Type of er ny of filtermaterial__- �v4-_r- * pfh'offfilter mC'-__aterial_______X- Width f trench____a-� ; �{ <br /> r <br /> Remodeling and/or repairing (describe)--------------- ----------- ---------------•------------------------------------------------------------------------------------------------------ <br /> ---------------°---------------------------------------- __:--;--------------------------- --- <br /> ------------------------------•------------------------=----------------------------------------------------------------------------------------------------------------------------------------------^---------------- <br /> ------------ - ------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> hereby certify thatII 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 /> i <br /> (Si ned � (Owner and/or Contractor <br /> - - --- ----------------------------------------------- <br /> By:--^------------------------------------------- ----------------------------------------------------------------------------(Title)--------------------------------------------------------------- <br /> - <br /> d <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be fled with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED-BY_------- ---- DATE_-------� 1_ ----------------------------- <br /> REVIEWED BY--•-----------`-------- -- -- - . /---1'�- --- . - . <br /> --- -- - - ------- -----------�;-------- - ------------------------------------------------ DATE----------- ------�----- <br /> ----------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations-----------------------------------------------------------------------------------------------------------------=------------------------------------------- <br /> ----------------------------------------------•------------------------------------------------------------------------------------------- <br /> ----------------------------11—--------------------------------- <br /> --• <br /> -f i Cft : _ --- <br /> --------------------------------------------------7------------------------------------------------------------- _------ ------- ---- ------------------` <br /> PERMIT No.----`�A:4--------- ISSUED------ 3�� --------------(Date) FINAL INSPECTION BY---------------- -`--- ----------------------------------------- <br /> Date <br /> ---------------------------------- a <br /> tDate--------- •-.-----�- - -- --------------------------- <br /> SAN <br /> -------------SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />