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Permit No. ----- -•--------�-pro <br /> APPLICATION FOR SANITATION PERMIT — <br /> (Complete in Duplicate) Date Issued <br /> +' is hereby made to the San Joaquin Local Health District for a permit to construct andains#allthe work 4ie�e'sn described. <br /> Applica ion y i.., <br /> This application is made in compliance with County Ordinance No. 549. t <br /> I , a.;. I ------ --------------- <br /> i <br /> s, e ---- <br /> JOB ADDRESS AND-LOCATION/_jam____-__--__--�-��--------- ---------�- <br /> ... ---------------------------- <br /> ---Name---------------.. ... j --------- --------------- <br /> Owner'sr- Phone <br /> .. <br /> ..� �. .. - �-• —,-- ` -----------••--- -­----­------------- <br /> Address <br /> - - ---------•--..._ <br /> Name -------•- 4 <br /> Address----------------------- f P ----------- <br /> . -------•_.. _ hone.------•---••---------� <br /> ------ <br /> Contractor's Nam. -----"-- --•-- --------- ---------- ------ ----•- f <br /> I ,., - 'Motel Odie <br /> Installation will serve: sResidence XJ';Aphrtmerit'House ❑' Commercial ❑ Trailer Curt ❑ ❑ ❑ <br /> r Number of living units: -------- Number of bedrooms-------- Number of baths -------- Lot size------ -- <br /> Private Depth to Water Table _ =ft:" <br /> Water-Supply: 'Public.system ❑ Community system ❑ p ` Adobe Hard an <br /> Character of soil to a depth of 3 feet: Sand Q Gravel [I Sandy Loam ❑ 'Clay Loam ❑ clay E] p ❑ <br /> Previous Application Made:: Yes ❑ No New Construction:"Ye No ❑ <br /> AND SPECIFICATIONS: ( ' <br /> TYPE OF INSTALLATION ' <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well ____Distance from -------------------- <br /> qhq <br /> ❑ ,. # No. of compartments------ -------- ---------•Size <br /> _Liquid depth-------------------------Capacity..-------------------- <br /> ll----------------- _ <br /> Distance from foundation-------------------- to ne <br /> Disposal Field: Distance from nearest wearest of ine----------------- <br /> ❑ Number of lines ------------------------------Length of each line------------- ------.Width of trench.---------------------- ----- V". <br /> "Type of filter material------------ -------Depth of filter material-------•--------------Total length--=--------•------------------- <br /> 6 <br /> � Seepage Pit: . ; Disfian`ce�to nearest well--­­ <br /> Nu <br /> ell -._;�_._ --:Distance from foundation___�. __.__..D•sstance toDnea}est,lot Ime-_tom <br /> ❑ Nu'mber of pits --_ --- Lining material-----------------------Size Diameter----------------------- p <br /> f _ . 9 -------------------- <br /> #r' Cesspool `�"� ��st�once from nearest well------------ ---Distance from foundation --- ---- __:Linin materialels. <br /> ❑ Depth --- --- - ---Liquid Capacity-- --------------� --s 9 <br /> Size: Diameter-_------ ----- " <br /> u - (�- T------------Distance from nearest building-_-----------„?-e----------,------- <br /> Privy: Distance from}nearest well---------- --------S � - <br /> ----------------- <br /> Distance toynearest lot dine -'-- --=='- ' it <br /> i ... = -•--------------------------------------- <br /> Remodeling and/or repairing (describe)---------------- <br /> -- ----------- <br /> h- = ------------ <br /> --------------------------------------- _ <br /> I;her eby certify that I have prepared this application and that the work will be done'in accordance with San Joaquin County <br /> San Joaquin Local Health District. <br /> 1 !� <br /> ordinances; State laws, and rules and re uiations o the ,._.. (Owner and/or Contractor <br /> .g <br /> 4 Si ned --------------------------- <br /> ---------------- E - 7'� t-------------------------------- <br /> E - �.wr"'-. )---------------------------- - ------------- <br /> fF; (Title) <br /> k(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 /> DATE----------- *� <br /> b S <br /> APPLICATION ACCEPTED BY------------------------------------------- --- DATE = = <br /> r REVIEWED BY--------------------------- ---- -------- --// <br /> - DATE ----------•-------------------------------------- <br /> BUILDING PER ISSUED----------------------------------- - <br /> -- . <br /> Alterations and/or.recommendations--------------------------- - ---- -- _ <br /> ------------------ <br /> ----------------------------------- <br /> .M- s' <br /> ------------------ <br /> --- ------- <br /> f <br /> �j <br /> --------------------------- --------;-------------- <br /> ----------------------------- <br /> ! -----------Y------ <br /> -. Date------='-----= <br /> FINAL INSPECTION-BY:..------ _------....... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> * <br /> 300 West Oak Street 132 Sycamore Street $14 North "C' street <br /> 130 South American Street Trac California <br /> Stockton, California Lodi, California Manteca, California y <br /> s�.. <br /> `� ccw-7m Revised W-2100 <br />