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APPLICATION FOR SANITATION PERMIT P mit No. .4z�t� <br /> (Complete in Duplicate) <br /> Date Issued <br /> grApplication is hereby made to the San Joaquin Local Health District for a permit to con truct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> I r <br /> JOB ADDRESS AND LOCATION____'___ <br /> Owner's Name----------------- ------------ .�_�_ --4c------Y------ ------------------------------- Phone----- <br /> ---AdAddress----------------------- <br /> dress----------------------- "' -----------" <br /> -- -- ----------------------- <br /> Contractor's Nama------------------------- ._ •__ � __-- - ----- Phone---- Z12- <br /> Installation will serve: Residence jg' Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel ❑ Other ❑ <br /> Number of living units: __Number of bedroom____ Number of baths -'2---. Lot size -------------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table-:Xo ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobelt Hardpan❑ <br /> Previous Application Made: Yes ❑ No J< New Construction: Yes ❑ No ❑ 41?1� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: `? <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> tic Tank: - Distance from nearest well-----------------Distance from foundation____--___________-Material______-_-----__-----___________________________- <br /> �� No. of compartments--------------------------Size---------------------------.-----Liquid depth.-------------------------Capacity-----------•- ---- <br /> Disposal Field: Distance from nearest well_/�k_-Distance from foundation__la:2 ____.Distance to nearest lot line.-Zd__/ <br /> Number of lines - -----Length of each line---s __________.Width of trench__ _`_ '________________ <br /> Type of filter material____/_'_e_-__ --_Depth of filter material______f_4!�______Total length-----=5®_''__________________________ <br /> yy�� r <br /> Seepage Pit: Distance to nearest well.f3f��------Distance from foundation_�__��___ __....Qista��a to nearest lot line---�_ ___. � <br /> Number of pits._.__________ ______Lining material- Size: Diameter__ __._-------.Depth__ _! _-_________________. 0 <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_________---__--___-__-_______--_____. <br /> . ..Size: Diameter.---- •--_- - - -------Depth --`------------------------------------------------Liquid Capacity -------------------- gals t <br /> Privy: Distance from nearest well"�_________________ _____ ____________ _Distance from nea�est-ouilding <br /> ❑ Distance to nearest lot line----------------------------------------------------------------------------•---------------------------- ----- •- <br /> Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------- ------•--------------------------------------------...--------------------------------- <br /> 3 <br /> ------------------------------------------ -------------------------------•----------------••----•---•-----------------------------------------------------------------------------------------------------•---------------- <br /> I hereby c rti that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, t e ! s, and rules and regulations of the San Joaquin Local Health District. <br /> A <br /> 1 , <br /> ( g Si ned P_---------(A-------------------------------------------- <br /> } Contractor) <br /> V J - <br /> BY -'` Title t t� --------------------- <br /> n' <br /> ------------------- <br /> a (Title) <br /> (Plot plan, showing size of lot, location of s stem in relation t wells, buildings, etc., can be placed on reverse side). <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------- --- =- ---------------------------------------------------------------- DATE-------- --- --------- <br /> REVIEWI D BY i+ - DATE - -- ._- <br /> BUILDING PERMIT ISSUED-------------- ----------------------------------------------------------- DATE-=-------------- ------------------------------------------ <br /> Alterations and/or recommendations---------------------------------------------- ----------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------- -------------------------------------------------------------- --- ---- ------------------------------------------ --------------------------------- <br /> FINAL INSPECTION BY------------ ---------------------------------- Date------------/ D J ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreet <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br /> J <br />