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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> OWd, ---------------- <br /> Applica'ion 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__..�_Z.I Z ------------------------------------------------------------------ <br /> Owner's Name_ --------------- Phone------------------------• --------- <br /> Address-- <br /> -------- <br /> ---Cc-�- !<;r----- ---- --------------- ----------------------------- <br /> Address--- -------- -------- <br /> (1)-------------------------- 4- <br /> --------------------------------------------------------------------------------------------------------------------- <br /> Contractor's Name_ -------------------------------------------- Phone/ye <br /> Installation will serve: Residence P4--OqTarfment House E] Commercial [] Trailer Court E] Motel 0 Other [j <br /> Number of living units: _/--- Number of bedrooms Number of baths ---t___ Lot size __-_--17 r~--.__A------t-0-0--------------- <br /> Water Supply. Public system A;. nrnunify system E] Private E] Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam F] Clay Loam El Clay [] Adobe 4""-,9pan C3 <br /> Previous Application Made: Yes E] No 4—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 feet.) <br /> Septic Tank: Distance from nearest well________________Distance from foundation.--..___.__._-_._-.Material_______.____.---__-----------_-_____-___________- <br /> No. <br /> aterial------------------------------------------------- <br /> No. of compartments---------- ---------------Size--------------------------------Liquid depth------- ------Capacity--------------------- <br /> "Disposal�ield'. Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line________-___----_ <br /> 16ANumber of lines----------------------------------Length of each line--------------- --------------Width of trench----------------------------------- <br /> /1r "_j0%b Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest welloo")!^0.41----Distanctloirom foyndafion_.W_,0_ --.Distance to nearest lot lin,__1 0- <br /> Number of pits......9*--------------Lining materiaIj1!jLtA4A__ Size: Diameter-ji-----------Depth-.-. Q---______--____- <br /> ------------------- <br /> Cesspool- Distance from nearest we4-----------------Distance from foundation....................Lining material__..____..____._________.____________ <br /> ❑ Size: <br /> aterial-------- ---------------------------- <br /> Size: Diameter------------------ --- ---- -- ------ Depth--------------------------------------------- ------Liquid Capacity---- ------------------gals. <br /> Privy: Distance fromnearest well.._.._..______._..._--__-----___.__--_ _.-_Distance from _ne_a_resf building------------------- <br /> -------------------- <br /> ElDistance to nearest lot line--------- ----- ------------------------------------------------------------------------------------------------------------ <br /> Remodeling and/or repairing (describe):-------- - ---------- -------------------------------------------------------------------------- ---------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------- <br /> ­-­---------------------------------------------I----------------­ ---------------------------------------------------------------------------------------------------------------------------------------------- <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, State laws, and rules and regulations o the San Joaquin Local Health District. <br /> (Signed)--- - ------------ -----I---- -- ---- ractor) <br /> - ----- -- ------------------------------------------------------- ------ <br /> By. -------------------------------- I_`--- ---- ------ ---- ---- ----------------- <br /> ------ ---(Title) <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY---------------- ----------------V,-------- ------------------------------------------- DATE------ --------------- <br /> REVIEWEDBY------------------------------------ -------- -------------------- ----------------------------------------------------------- DATE----- ----------------------------------------------------- <br /> w <br /> BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------- DATE.------------------------------- <br /> Alterations <br /> ATE--------------------------------Alterations and/or recommendations:---------------------------------------------------__------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------­-- -------------------------------------------------------------------------------- ------------- - <br /> ---------------------------------------------------- <br /> -------------------------------­­----------------------------------------------------------------------------------------_----------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------- ------------- --- ---­1-------------------------------------­­...... ------------- --­­-----------------------I—,------------------------------- <br /> ------------------------------------ ---------------------------------------------------------- ------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:--- ------ <br /> ----------------------- ------------- Date.......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Scufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreof <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> Er;-9-2m 145446 ATWCDD 12-54 <br />