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- : <br /> APPLICATION FOR SANITATION PERMIT Permit No. __G_---:---------- _ <br /> (Complete in Duplicate) <br /> . Date Issued ---------__- <br /> L 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 No. 549. <br /> -------------------------------- <br /> Owner's <br /> - <br /> ,. JOB ADDRESS AND LOCATION-------- ---------------------- ----------------------< --------------------------•- <br /> Owner's Name-------------•--� d--••-----• ---•-------•- -,------ --•-----------------r-------- <br /> Address , <br /> ---------------•-------- <br /> o ------------------------- <br /> ---------------------------- <br /> ".' --- ---- -------•- --- `''' <br /> Contractor's Name--- •------------------------••-•--------------------------------------------- •-------------- Phone <br /> Installation will serve: Residence ['/Apartment House ❑ Commercial ❑ Trailer Court❑ Motel ❑ Other ❑ <br /> Number of living units: --I____ N mber of bedrooms _�_ __ <br /> Number of baths _ __--- Lot size ______S..__ ._��________________--_____ <br /> Water Supply: Public system Community system ❑ private ❑ Depth to Water Table -------- ft.. <br /> Character of soil to a depth of 3 feet: Sand Gravel E] 'Sandy Loam ❑ Clay'Loam E] Clay E] Adobe�Hardpan E]Previous Application Made: Yes E] No New Construction: Yes �T'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 ...Distance from foundation__le_ .____.Material__.''�'~�l-> -_� ' <br /> `}—. ------- Size---q Y_v X4--------Liquid depth.-----..(4- ------- Capacity ------------------ <br /> Disposal <br /> ' <br /> Nn, of compa'rtments_....... _-.-_ --------- <br /> Disposal Field: Distance from nearest well. '"-Distance from foundation_./_t.__ _.�__-.Distance to nearest lot hne__45�_....... <br /> Number of lines------------------------ --- - ---Length of each line-.Ir '(IJ+_1J----.-.Width of trench.___-A_e._______.._-__.--.... <br /> Type of filter material__ >„___.-_--Depth of filteF mat erial__. -------------Total length----- ____________________-_._ <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: <br /> _ .-----------Cesspool: Distance fromi nearest well-----------------Distance from foundation-------------------.Lining material_____________________________________ \ <br /> ❑ Size: Diameter------------------------------ ------Depth-------------------- ---------._._....------------Liquid Capacity- --------------------gals. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building__________.__-----__--_________.___--.-_. <br /> 1. <br /> ❑ Distance to nearest lot line-------- --------- ------- -- ------------------------- --------------•-•-•-•----------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):-- --------------------------- ------ --------------•-----------------------------------------•-------------------------------------------------....... <br /> E <br /> ----------------------------------------------------------------- <br /> ----------- --- <br /> ---------- -----------•-•------------------------------•------••----•-- -----------------------------------------•-------------------------- '-----------------••-------------••-------------•------------ <br /> -----------------------------------•-=-1----•------------------•---------•----------••----- ----------- --------------------------•--------------------.------------------------------- --- -------- <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 law and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)--�------------- ---`------- ----- - `' -------------------- --- --- ------------------•-------------------------------- --:--------(Owner and/or Contractor) <br /> ____(Title)_ <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 /> REVIEWED BY - ----------------- ------------------------------ DATE --- -- -'"�7�--- �` <br /> BUILDINGPERMIT ISSUED------------- --------•- ----------------------------------•--------------•------------------------ DATE--------------------------------------------------------- -- <br /> Alterationsand/or recommendations:---- ------------------------ ------------._.-..-.------------------------------------------------------------- -_-•---•---•--------•------------------ <br /> -------------------------------------•-------------------,--------------------------- --------­­------------------------------------- <br /> ---------------------•---------------------------• `----------------------- -_------------------------------------------------ --------------- ------------------------------------------------------------------- <br /> I <br /> l <br /> FINAL INSPECTION BY: I <br /> � Date---- ---------- <br /> SAN <br /> 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 /> E5-9-2M 145446 AT W❑OD 12-54 <br />