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� � 57 cc <br /> APPLICATION FOR SANITATION PERMIT Permit No. .--P.. a-. .. <br /> �—� (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 /> This application is made in compliance with County Ordinance No. 549. <br /> l <br /> 3G----------------------- <br /> JOB <br /> ADDRESS AND LOC TION = o _ 'a-�--------- -- <br /> Owner's Name -- <br /> Address <br /> � �..- •�!V - ------------ -------- Phone-A--------------- ----- <br /> '/ ,,// <br /> Address-------•-••--- -----------------------4'- ----------- --- --------------- - ----------------------------'-------------------------------------- <br /> - ` <br /> I ' <br /> Contractor's Name------------------------------------------------------- -------------- -- - - ---------- --------------------------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ C'o'mmercial E] Trailer Court El Motel E] Other ❑ <br /> Number of living-units: --/--- Number of bedrooms umber of baths ._. --- Lot size ------------ -Igr---------- <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 ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AclobeA!� Hardpan ❑ <br /> Previous Application Made: Yes EX,.,No ❑ New Construction: Yes ❑ Nox <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-_--_/Z..._.Mate ial----- .__._._------------- ------------------- <br /> No. of con-,partments.......rz,-----------Size---&-> -��- Liquid depth___----I�....____-___CapacitY___+��...___ <br /> Dispas I Field: Distance from:nearest well___C--�_ Distance from foundation- f_�____Disfance to nearest lot line <br /> - <br /> Number of lines-------------�------- -- .- Length of each line___::---_1-�-----__---Width of trench---.__--��+____ . --_-- <br /> -' .""___Total len �-�-------- <br /> Rj <br /> Type or filter material____ ------Depth of filter material---------�? th--------------------- <br /> _._ g <br /> Seepage Pit: Distance to nearest well--------- ------------Distance from foundation-------------.------Distance to nearest lot line----------------- q , <br /> ElNumber of pits----------------------Lining material-----------------------Size: Diameter----------------- __Depth --------------- <br /> Cesspool: Distance from Inearest well-----.-------------------Distance from foundation--------------------Lining material-------------------------------------- <br /> F1 <br /> _---.___--_-.- _----.--.--._.-.❑ Size: Diameter--------------r-----------------------Depth--------------------------------------------- ------Liquid Capacity_.---------- ------.------gals. <br /> Privy: Distance From!nearest well------------------------------------.------------Distance from nearest building---------------------------------- <br /> ❑ Distance to nearest lot line---------------------------------------------- -------------------- ---------------------------------------------------------- ----------- - i <br /> r <br /> Remodelingand/or repairing (describe):----------------------------------------------------------._....-------------------------------- ------------------------------------------------------ <br /> - \i! <br /> ----- -----------•------------------------- -------------,-------------------------------------- <br /> •-- ---------------------•-----------••--------­------•----------------••--------------------------------------- <br /> ------------------------------- - <br /> I hereby certify that I have prepared this application and that the work w'I1be done in accordance with Sari Joaquin County <br /> le ordinances, State laws, and rules and regul tions of the San Joaquin focal ealth District. <br /> Q� <br /> {Sig�ied) °'�..� �G• l r--�- - �--------- - (Owner and/or Contractor) <br /> I (Title)------------------------ <br /> /By------------------------- ---------- -------------------------------------------- ----- <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..--3 -----------•-- - --- - ---- ------ f - DATE f <br /> REVIEWEDBY--------------------------------- -.. ------- DATE----------`--- ---- -------------- <br /> BUILDINGPERMIT ISSUED----------j---------------•------------•--------------------------- --------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or re ammendations------- <br /> I � � =- " <br /> -- --------•---------------- --------- r <br /> -----•----------------------------------- -------------- ---------- ------------------------- •---------------------------------------------•--------------------- ----------------------- - <br /> I----------------- ----------------------------- --------------------- - ----------------------- --- ------------------------------------------------------------- <br /> FINAL INSPECTION BY:. , <br /> bj/ --- <br /> - Date - -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street f 32 Sycamore Street 814 North "C" Street <br /> Stockton, California k Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 0-52 Revised W-2100 <br />