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APPLICATION FOR SANITATION PERMIT Permit No. ._-_.-- <br /> 1" (Complete in Duplicate) � <br /> vV 1l Date Issued -_ _-�--5-___._- - , <br /> Applica-ion is'ereby made to the San Joaq in 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. a <br /> JOB ADDRESS AND LOCATION____.__!_ -_ ---------------------------�+��!)-��>= --------------- <br /> Owner's Name � - �-----�.`J. ------------- ---- -- �-- - °fP <br /> hone------------------------------------ <br /> Address. <br /> ' -- ------------------ - ------------------------ <br /> = <br /> Contractors Name--- -�"_' , --------- Phone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot9l ❑ Other <br /> Number of living units: ___[-_._ Number of bedrooms -�j_ Number o 'aths ..L-__- Lot size ___ _ ` t9__---__---_--_____--_.__-- <br /> Water Supply: Public system E] Community system ElPrivate Depth to Water Table .__...., ft. <br /> Character of soil to a depth of 3 feet: Sand4 Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes [✓ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> j (No septic tank or cesspool permitted if public sealer is available within 200 fee ) r ► " <br /> Septic,,Tank: Distance from nearest well— _ SDistace frora foun ton _ _---_ _ _M,aterial <br /> No. of compartments_.___...__ __ _ _x_ ___Liquid qepth� --- <br /> _-�-._--____..Capacity___ <br /> Disposal Field: Distance from nearest well -_ Distance from foundation/ __ uL�'Stante to nearest lot line_�I_ _ �°� <br /> Number of lines-_.._..__ _ Length of each line ____ _,,--.Width of trench______-2 ____..._1-_--.-__. <br /> Type of filter material R.1_1A,_. ------------Depth of filter material....._..__- -----..Total length______________ _r� _�---___---..- <br /> Seepage Pit: Distance to nearest well------------- --------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> 0 Number 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 /> 10 <br /> ----------•---------•-------------------------•-------------------------------•-------------------------------------------------------------------------•--------------------------------------------------•------------------ <br /> -------------•----------------------------•--------------------------------•-------------------------------------------------------------------------•--•------------------------------------•-------- •-------------------- <br /> ------------------ ----------------- ---------•----------------------•--------------------------- •-------.---••----------•-------•------------------------------••----------------------------•------------------ <br /> I here6y 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).. ;rte- - - -----------------(Owner and/or Contractor) <br /> By:: `3°j-..��..._.._.., .fes!?: `. '_A. ......0� --------------------------------------------(Title)-------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 6e placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ._ _______ <br /> REVIEWED BY------------------- ------ DATE '' ---•-----•-- <br /> e_ ------- <br /> BLIILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---.fig--------------- <br /> Alt1,Ations and/or <br /> recom_m.e_nd_ a.t:io`n's!:- s -----------I--- ------------------------- <br /> ------------------------------ <br /> ---------- --- ---------------------------------- <br /> - <br /> -•-•----- ------------------ <br /> --- -- -•-----•-----•------------- <br /> - - ------- <br /> �'~ .. -----`------ ---- -------------- ----- +" '` 'fit"-----°1--------- -'' -7-------------------------------- - <br /> ------------------------------------ ------------------)--------------------------------------------------------------------------------------------- -------------------- --------------------- ----•- -------- <br /> `y /may <br /> FINAL INSPECTION BY:------` ... --- --- --------------------------- Date. /`r 5�__. ------------------------------------ <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 /> k: E5-9-2M 145446 ATWOOO 12-54 <br />