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APPLICATION FOR SANITATION PERMIT Permit No. <br /> off (Complete in Duplicate) 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 /> 's application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND 4--9CATION.- 6 Z <br /> ------------ -- --- ----- -------- --------------------------------------------------- <br /> N <br /> Owner's Name----- ­ -- ---- --------------------- ---- ------------------- ---------- Phone-,------------------- <br /> - --------- <br /> Address----- .. . ...... ------------ <br /> _tor Name <br /> Contractor's Name------------- ------ - ---------------------------------- ---------------------------------------I-------------------- Phone.-7-7,/ 4�e_ <br /> Installation will serve: Residence lg,-Aparfmenf House E] Commercial El Trailer Court [] Motel [I Other Ej <br /> Number of living units: ---- -- Number of bedrooms-.3--. Number of baths Lot size .... <br /> - -------------------------- <br /> Water Supply: Public systemX Community system El Private F1 Depth to Water TableO�ft. <br /> Character of sail to a depth of 3 feet: Sand 0. Gravel 0 Sandy Loam [] Clay Loam E] Clay El Ado Hardpan <br /> ❑ <br /> Previous Application Made: Yes 0 Nox New Construction. Yes. No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 jf <br /> / --&?ILJ <br /> Septic Tank: Distance from nearest well-__ Disfance from founclatio �7 <br /> . .......Material___ <br /> No. of comparfmenfs__.t ------------- ")1--7- <br /> Li ------ Capacity..---r ---- <br /> Dispos91 Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line----------------- <br /> Number of lines------------- ------------- <br /> Type of filter maferiai.__,,--------------------Depth of filter material----------------------Tofal <br /> ----------- ......Length of each line---------------------- <br /> ........Width of trench--------------- <br /> See e Pit: Distance to nearest well__- <br /> Disfancej from foundation---_41�-___._-._.Distance to nearest lot line--./d;, <br /> Number of pits------ - 4 <br /> J------ - --Lining materiaI4��`_A� '-f Size: Diameter-----r�- -- ------Dept h-----------0;2 <br /> ------------ <br /> Cesspool: Distance from nearest well-------------- ___Distance from foundation-- -- --------------Lining material-____.--_---__.__.________ <br /> El Size: Diameter------------------ -------------------Depth--------------------------------- ------- ----------Liquid Capacity------- ---------- <br /> Privy: Distance from nearest well----------------------------- ----------_-.-Distance from nearest gals. <br /> El Distance to nearest lot line----- - ------------------------ ------------ <br /> __(---- ------------------ ------------------------ <br /> /le in x <br /> g and/or repal (de <br /> -------- <br /> -------------- <br /> ---------------------------- - ----------------------------------------------- --------------------- <br /> ...... ... ---------------------------------------------------------------------------------- -------------------------------------------------------------------------- ----------------------------------------------- -- <br /> - ----------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------­-----------------I----------­­ t <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, Aa Sf <br /> I �fe law", 91-rules and regulations of the San Joaquin Local Health District. <br /> (Signed)•. ...�_/6. -------I------------------------ <br /> ,// <br /> ------I------------------------- -------------------------------------------------- ---------- --------- --- ---(,Owner and/or Contractor) <br /> ov <br /> By:----•--•---------------/ U'- <br /> ---------------------------------------- ---------------------------------------------(Tif le)------ - ----------------------------------------- <br /> rs <br /> d /reverse side). <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pl��cXe� <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ---------------------------_ ---------------------------------------------- DATE--------- <br /> REVIEWEDBY--------------------------------------------- ----------------- -- - -------------------------------------------•-- --------- DATE---- ----------- <br /> BUILDINGPERMIT ISSUED---------------- --------------- ---------- ------------------------- --------- ---------------- DATE.-------- --------------------*------------ <br /> ------ ------------------- <br /> Alterations and/or recommendations'--------------------------- 1`:------------ <br /> ------ ... .. .. --------------------------------------------- <br /> ------------------------ --- - --- -- - ---------------------- <br /> --- ------- ---------- -- --------7----------------- -------- -------------0------- <br /> ,I - - -7--�------------------------ ---------------- ------ <br /> ------ <br /> ------------- ----- <br /> ------- ------------------------ ----------------- <br /> ---- <br /> ---------------------------------------- --------- <br /> ----------------------------------------- --- ----------------------- - ---------------------------------------------------------------- ------------------------------------------------------------ <br /> FINAL INSPECTION BY_________________ --- --------- -------------------- Date---4--f. -1 C.�� <br /> - �---------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wed Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-21M t45446 ATWO30 12-64 <br />