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6LI <br /> f APPLICATION FOR SANITATION PERMIT Permit No. "Y_4______________ <br /> (Complete in Duplicate) sl- <br /> 1 � � I Date Issued <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 is made in compliance with County Ordinance No. 549. <br /> t& <br /> JOB ADDRESSND OCATIO --` d-6__ ---'�1---- - - ----------------------------------------------------------------------------------------------- <br /> -------- - --- - ------------- <br /> OwnersName---- -- --•- ------- -_ -----------•------------------I------ -- ---4--R•---p--•-------------------- -------------------------------------------- Phone----p- <br /> Address pfir ----- - ---- - ------------------------------------------------------------------------------------A-------- <br /> �-- <br /> ----- <br /> ------------- <br /> Contractor's Name_____ �--•-- '"`- ---- -----------------------------------•-----------•------------------•--...---- ^ -------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of living units: _ ,_.Number of bedrooms _3___ Number of baths _ - Lot size <br /> Water Supply: Public system B--l-c-ommunity system ❑ Private ❑ Depth to Water Table <br /> Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe J�O/Hardpan ❑ Q <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ 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. of compartments--------------------------Size--------------------------------Liquid dep.'h -------------------------- <br /> Capacity <br /> Disposal/Field: Q Distance from nearest well *?0r..J..Distance from foundation____J_�_____...Distance to nearest to lin <br /> Number o{ lines________________ __ r/ <br /> [ � �/w _ Length of each line_______ Width of trench__________-__ <br /> Type of filter material__/!._ __ _.______Depth of filter materlal____._1__ Total length----____-_�-S_____________________ <br /> ��jj � <br /> Seepage Pit: Distance to nearest well-__ ft+^ ___Distance from un tion______I_sI__._..Distanc to nearest lotli� 1s�_ <br /> Dumber of pits___.__.__----------Lining material-C'___- - ize: Diameter____--Yr,�_---___..Deptn___.....________________________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_____-________._____________________ <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building.._._________._______._______._.._____._. <br /> ❑ Distance to nearest lot line----------------------------------------------------------------------- -------------------•-------------------------------- --- -- -------- - <br /> Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------- ---------------------------------•------------------- <br /> ------------------------ ------ ----------•--••------------------••--------------------------------------------------------------------------------•---------------------------------------------•---•---------------- <br /> -----•---------------•---------------------•-----------------------------------------------------------------------------------------•-------..........--------------------------------------------------------------------- <br /> ------------•--------- ---------------------------••----------•--------•--------- ----••-------•---•---------------------------------•----------.----•--------------------------••----•----------------------------------- <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, a laws, anArs and regulations of the an Joaquin Local Health District. <br /> ($igned} *'- - ---- -IV -------------- -- -------------------------------------------------------------------(00m. and/or Contractor) <br /> -- -By• -------------------------------(Title) <br /> ------------------------- <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 /> APPLICATION ACCEPTED BY--- ----------- - ------------------- --------- ------------------------------------------------ DATE-�---------------------- - <br /> - ---------------------- <br /> REVIEWED BY------------- ------------------------ DATE <br /> BUILDING PERMIT ISS_U__.E__D-------------- <br /> I------------ --------------------------.----------------------------------------- DATE-•------ <br /> Alterations and/or recommendations:----------------------------------------------------------------------------------------•-------•-- --•---- <br /> ---•---•-----•-- •-•-----------------------•------ -••-------------------------------------------------------------------------------------------------------------------•--------------------•--------------------- <br /> ----------I------------------------------------------------------------------------------------------- -----------------------------------•------------------------------------------------------------•--------------------- <br /> --------------------------------- ------------•-------­1------------------------------------------------------------------------------------------------------------------------------- ------I-----------_-------------- <br /> ---------------------------------------------------------------------------------- -------------------------------------------------------------•--------------- ------------------------------------------------ <br /> FINAL INSPECTION BY:----------- ''l"� f ------------ Date---------------------- y --- ------------ <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 /> ES-9-2M 10.52 Revised W-2100 <br />