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`y : / ,y APPLICATION FOR SANITATION PERMIT Permit No. <br /> "(C+ plete in Duplicate) <br /> Date issued ---------------------- <br /> f i <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 iIs made jin compliance wif_h County Ordinance No. 5 <br /> O <br /> JOB D DESSame_AN }, CATION--' = /- ------- <br /> �' -�-_-.-�: --- - - -- - -- -- - _ Phone__ i-.__ <br /> A dres,(--- <br /> ,t --- -------------- -------------------------------------------------------•- -- <br /> F ontractor' ame____----------------------- <br /> VO' <br /> _ o <br /> „ =I � � ----------- - = 7- <br /> __�__ __ Phon,/­ <br /> Installation seiillNf 11serve. Residence : Apartment Ho } # ; <br /> p t use' ❑�Commercial ❑ Trailer Curt tE1 Motel Other ❑ <br /> I Number of living units: ___ : Nu bar of bedrooms__ Number of baths _�____ Lotsize___,/Q_Q,: o2�_d-------------------- <br /> Water Supply: Publi( system Community system [I ' e <br /> ❑ Depth to Water Table ft:'4�� <br /> Character of soil to a depth f 3 feet: Sand ❑ Gravel ❑� Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob '' Hardpan ❑ <br /> { PPrreviops Application Made: Yes ❑ Nog New Construction: YesX. <br /> No ElFHAY VA: Yes..0,j Nc ' <br /> TYPE OP INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> ptic T nk: Distance from nearest well-----------------Distance from foundation------------.-------Material__ ____i._________---`._________ ______._____. <br /> No. of com arfinents_ _____.Size_ _ Liquid de th_.j_ _ __. �` _Ca acit <br /> p q p 1 ` ------- p� y---------E------------- <br /> Disposal 'eld: Distance from.nearest w.elf______________._D,istance from f_oundat:ion____-__________.__.Distance to nearest to line.______._.___.__ <br /> Number of line's- --------------------------------Length of each line------------------------------Width of trench.-------------------- ------------- <br /> Type of filter material-------------------------- of filter material------------------ __Total length__________'___`__._______._____________ <br /> Seepa a Pit: Distance to nearest well_,._:______Distance from fflundafion _.Distance to pearest lot line <br /> Number of pits_.F_-/-------------Lining ma�terial,r� - _______Size: Di eter___ <br /> C sspool: Distance from nearest well_______________ Disf'ance from foundation__!-----------------Lining material------------------------------------- <br /> ❑ <br /> - Size: Diameter-- k=-= -------------- -------------Depthk-------- ---------°----------I---------- Liquid Capacity----------------------------gals. <br /> Distance from nearest well------------------------------------------------Distance from earest building----------------------------------------- <br /> Privy: Distance to nearest lot line------------------------------------------ '`------- <br /> I -------------------------------------- <br /> Remo <br /> ------ --- ------- <br /> {- ------ -- <br /> Remo d/or repairing (describe):---__ 1 I <br /> - --------- -•--------------:---------------- --------------------- <br /> --------------- <br /> ------- ---------------------•----------------------------------------------- ----------- <br /> f I hereby certify that I have prepared this application that the work will be done in accordance with San Joaquin County <br /> ordinances,,5iate law;, nd rut an egulationf the Jo a in Local Health District. <br /> J r(Signed) -- r d/or Contractor) <br /> {O <br /> AL <br /> By:. Title ----- ----- ---- -------I i------------- <br /> (Plot plan, showing size of t, location stem in a ation to wells; buildings, etc., can be pl ced on ve side). <br /> 1 <br /> FkOR_DEPARTMENT TMENT USE ONLY. <br /> APPLICATION ACCEPTED BY .. <br /> Y � <br /> --------------- DATE----------------------- <br /> T ---"-'--------'-"---'------- ----.--------------------------" - '-'---__f-� ------------- ; <br /> REVIEWED BY QATE- '`� -------------- <br /> BUILDING PERMIT ISSUED---------•-- {f ,. — >DATE t <br /> --- ---- -----------------=------------- - <br /> Alterations and/or recommendations.._____..___ `�' <br /> n - --------- <br /> - <br /> ° Y -------------- -------------------------- -------------------------------------------------------------_---- -•--------- -------- <br /> - <br /> ------ ----- - <br /> �- -r= --- ------ -------------------------------------------------- ----- . --- ------ <br /> ----• --- -- -------- <br /> --- --- _ <br /> FINAL INSPECTION BY:.-------- - - --------- --- ---------------- Date------ ----------- <br /> SAN <br /> ---------SAN JOAQUI'N LOCAL HEALTH DISTRICT <br /> 130 Soufh American Street 300 West Oak Street 132 Sycamore Street j 914 North "C" Street V q' <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-4=2M Revised 1.57 F.P,CO. <br />