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4 <br /> APPLICATION FOR SANITATION PERMIT Permit No. ..--1•2�._. ..�.Jr <br /> (Complete in Duplicate) !4 I j <br /> Date Issued ---- <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 o. 549. <br /> JOB ADDRESS A LOCATION------- ----eel .-- ----------- - - --------- - --- -- - -- ----------------------------------------- <br /> Owner's <br /> ----- ------------------------------•Owner's Na - -- ----- ------ Phone <br /> twtc� ' <br /> Addres - ---------- --------------------------------------------------------•--------------------------------------------------------------- <br /> Contractor's Name-------- ------ ---------•------------------------------------------------------ •------- --------------- Phone----------------------------------- <br /> Installation will serve: Residence, Apartment House ❑ Commercial ❑ Trailer Court -❑ Motel ❑ Other ❑ 1 <br /> Number of living units: __Y--- Number of bedrooms . .. Number,of baths .J""- Lot size -.. ."- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl"ZI ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe' Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes No F] <br /> TYPE OF INSTALLATION AND SPEC FICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> i <br /> Septic Tank: Distance from nearest wellixs.0'Distance from fpundation ----------Mat9rial_ -----r .. .--- --- ----------- -------------- <br /> � i <br /> No. of compartments... _--_--____.,,Siz .,x� Iiquid depth-.., ._. Capacity.... <br /> Disposal Field: Distance from nearest well---��Distance from foundation.-. �f. __--_....Distance to nearest lot line----- <br /> Number of lines-_-/------------------------ <br /> "� � ....___ Length of each line_...... .�__-. Width of trench.......�/ -.-.�...."__.._-__-, <br /> Type of filter material . _ .-__ .. .-._Depth' of filter material.....---f ___-__-Total length.___....._L -d <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation----------------....Distance to nearest lot line----------------- <br /> El . Number of pits----------------------Lining material----------.-------------Size: Diameter-----------------------Depth..------------------------------- W <br /> Cesspool: Distance from nearest well-----------------Distance from foundation....................Lining material-____------..-.-----.---.-....._---- <br /> ❑ Size: Diameter---- ------------------------- ----.DePth------------------------- <br /> - -------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well--------------------------------------------------Distance from 'nearest building------------------------------------------ <br /> ElDistance to nearest lot line-------- -------=-------- ----------------------------------------- --------------------------------------- ----------------------------- <br /> Remodeling and/or repairing �d'escribe):: . __ f_"" " S <br /> --------------------------------------•-------•---------------•------.-----..--------.-----.-----------------.--------------------------------`--------------------.---------.---------------------------------------------- <br /> ---------------------------------------------------------------------------------------------- ------------------------.-..-.........---------------------------------------------.---------------------------------------- <br /> v <br /> -------------------------------- ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I hak�,e prepared this application and that the work will be done in accordance with San Joaquin County <br /> ws, andifules nd regulations of the San Joaquin Local Health District. <br /> ordinances, Stat <br /> (Signed)---- ----- ..... .. .- - (Owner and/or Contractor) l <br /> ------------------ ----------------------- ------ - ---------------------------- ---- ----- <br /> BY• -------------------------------------- --- ------•-----•-----------------------Title ?1- = s <br /> 1 � .. ) <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed o everse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY9-------- - DATE-,-=—---------------------------------------------------- <br /> REVIEWED BY---------------------------� -- ----------------------------------------------------- --- -- - ------------.. DATE--Tf\ ------- ----------------------------------------- <br /> E <br /> BUILDING PERMIT ISSUED------------•-•--------------------------------------------------------------------------------------. <br /> Alterations and/or recommendations:.-.-------...................... <br /> -------•-•-----------------------------------------------•----•---••-•------------------------------------------_--•----•--...............------------------------------------------------------ -----------------. ------- <br /> -----------------------------------•----------•------------•-------------------------------------------- ----------------------- --------------------------------------------•-------- <br /> f <br /> FINAL INSPECTION BY:......... P ..,. ------ Date...." ' ----------------- ----------------------------------- <br /> SkN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street est Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California 4 )di, California Manteca, California Tracy, California <br /> ';j:. ES-9-2M 14544r ATWZ30D 12.54 -_ <br />