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APPLICATION FOR SANITATION PERMIT . Permit No. -----s17 <br /> (Complete in Duplicate) I ; <br /> Date issued -----PIV5-57 <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereilg clescribed. <br /> This application is made in compliance with County Ordinance No. 549. ���/ <br /> JOB ADDRESS AND LOCATION...._._.___ y�S- _.- --------- <br /> Owner's Name----------------_- � � ![ `fir�y �W <br /> 'at `�'�-�- �- ------------------------ --------------------------- <br /> �------------------- Phone----•--------------•--•-•-- I <br /> Address-------------------------------------------- 1_- � ------�----,----------��" <br /> Q �E ........i ------------------------------------ <br /> Contractor's Name---------- -----. Phone----------------_-- _------------ i <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel her ❑ I <br /> f . ___ Number of baths . __ Lot size __._ - ��s�d.'X6D <br /> Number of living units: _-..___. Number of bedrooms .. --"--- ---- <br /> Water Supply: Public system ❑ Community system ❑ Private 2r--,D-epth to Water Table . 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 [il""N�-ew Construction: Yes 2",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_4�0I--..._"Distance from foationlP.-___---.--- Material_. 7r '_.___._-.______.__---. <br /> p No. of compartments---------�-----------Size_ Y_3__X__5_------- --Liquid depth---�------------------Capacity----91- ------- <br /> Disposal Field: Distance from nearest well464P--->f"_,Distance from foundation-_ -----------Distance to nearest lot <br /> © Number of lines.___.-_-_".----"- Length of each line-----5�._-_-__"..........Width of.trench_ __r---------- _"_-___ <br /> Type of filter materiaLi.�C�t -Depth of filter material_... '�_...__.Total length...../J__a__"""_-____----__---_. <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line..---_".------_-- <br />' ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well----------------- from foundation-- -----------------Lining material--"_"..-.----_"-- ------------------- <br /> ❑ Size: Diameter--------------------------------------Depth------------------------------------.---------------Liquid Capacity-.--------------------------gals. <br /> Privy: Distance from nearest well------------------------------- -----------------Distance from nearest building.--__-.---_--..._-----_----__-__.-___.___. <br /> ❑ Distance to nearest lot line-------- ------------------ --------- --------------------------------------- ---------------------------------------•---------------------- <br /> Remodeling and/or repairing (describe):_...----- ------------------------•--------------•--------------------------•-----------------------------------------------D <br /> .a' <br /> •-------------•----------------------------•------------------------------------------•--------------------•---•-------------------------•----------------"•-•------------"--"-------•------------------------------------- �N) <br /> -------•------------••-"-------------------------•---------------"•---•---------------------•--"--------------------------------------------- V}`� <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 of the-San Joaquin Local Health District. ^� <br /> (Signed)----------------•-- <br /> .�'.��i� rxr-� -J------ --------- ----------------------------- ------------------- ............Owner and/or Contractor) <br /> By:------------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------------- ------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ,, .._. --- -------- -------------------- DATE---- - <br /> REVIEWEDBY----------------------------------- - ----- ------- ------------ ---------------------------------------------------------- DATE------------------------------ --------------_------------ <br /> BUILDINGPERMIT ISSUED-------------------------------------------------- ---------------------------------------- ••---- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:--------------------- --- ------- ------------------1" ----------------------------------•-------"--------------------------------------------•----------- <br /> ---"--------------•------------------------- ------- -------------------------------- - ------------"--------------•--• ---------------•-"---------------...---•---------------------•-----------...---....---•------------ <br /> ------------------------------ --------------------------------I----------------------------- ----------------------------•- ----------------------.-------------------------------------------------------------------------- <br /> -------------------------------------­--------------------- --------------------- -------------------------------- ---------- ------- --- ------------------•---------------------- <br /> FINAL INSPECTION BY:- - ----- ------------- Date---- J — -----'---- --------- ------- --- ----------- <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 /> EE-9-2M 145446 ATWCCD 12-54 <br />