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APPLICATION FOR SANITATION PERMIT Permit No.�o-- ----------- <br /> {Complete in Duplicate) Date Issued '7 y <br /> } / M <br /> K � � <br /> Applica-%n is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This a-pplication is made in compliance with County-Ordinance No. 549. Ft <br /> 4 JOS ADDRESS AND CAT ON._ __ <br /> Owner's Name _._ r�� f ---------- - ---------------------------------------- Phone 3- � <br /> Address... - --- ---- ------------- - ----------- --- ---------------­----------------------------------------------•-------------------------------------- ----------- <br /> Contractor's Name-------- •• -- --}--------=---------------------------------------------- ----------------- Phone-- If <br /> Installation will serve: Residence` Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel their ❑ <br /> Number of living units: __/�__`Number of bedrooms-4-'- Number of baths aZ-_ Lot size r __ -_ ________ -------------- <br /> Water Supply:x Public ) !em ❑ Community system E] Private` Depth to Water Table�Q_ ft. r <br /> Character of soil to a depih of 3 feet: ; Sand ❑ Graven•❑; -Sandy Loam ❑ Clay Loani Clay❑ Adobe❑ Hardpan ❑ <br /> Previous Application Mede: Yes ElN NewfOonstrucfion: Ye No ❑ A i <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pubiic sewer is available within 200 feet.) �C3` <br /> S ptic T4: Distance from nearest well_________________Distance from foundation-------------------Material------------.-------------------._______________- <br /> ❑ No. of compartments----- - ------------ Size-------------------------------•Liquid depth-------------- -----------Capacity_-------------------- <br /> Disposal Fie)& V Distance from nearest well_._._______-.__Distance from foundation--------------------Distance to nearest lot line----- <br /> Number,of lines----------------------------------Length of each line------------------------------Width of trench-------.--------------------------- <br /> Type of filter material________._.----___._.__Depth of filter material----------------------- length__-.-.-.____________-___________---_.---- <br /> � /� � r <br /> p I well____ ._------Distance om,fo dation__ <br /> w See a e Pit: Distance to nearest C�.____....{)ISt Ince to nearest lot line_____ __._____ <br /> 0 <br /> Humber of pits___ ________________Lining materi cS___Size: Diameter___ ,, __...__..--.-Depth____PL�--_--_____________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------ <br /> ❑. Size: Diameter------- ------------------------------Depth----------------------------------------------------Liquid Capacity gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------.-__________-__..--. <br /> j ❑ Distance to nearest lot line- ------------------------------------- ------------ --•-- ------------- ---•----- <br /> ---------• �------- ----`---------;--- ------------------------- ---- <br /> Remodeling and/or repairing {describe: �`�' <br /> f <br /> -----------------------•------------------------------------------------------------- <br /> ---------------•------------ -------------•---------•�---•--. -------------- ------------------------------------------ - ------------------ <br /> ------------------------------------------------------------------------ <br />' ---------------- ---------- -------------- ------------------------------------------------------------------------------------------------------ <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, Stat ws,filleand regulations of the San Joaquin Local Health District. --------- ----(Owner /oContractor) <br /> (Signed)--------- ------ - -------------- <br /> BY� ------ --------------- -------------------- ------(Title(Plot plan, showing sizeati n of system in relation to wells, buildings, etc., can be ed on reverse si�d�f.� <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION,ACCEPTED BY E - ' ` ---------------- -- _x---------------------------- DATE------------ . .: f� 5- <br /> -------------- <br /> REVIEWEDBY----------- -------------------------------- --------\---------- -----------------------------------,---------------------- DATE------------� --------------------------•------------ <br /> I � ' <br /> BUILDINGPERMIT ISSUED------------------------------------ ---------------------------------------------`- -----• DATE----------- ------------------------------------------------- <br /> Alterations and/or recommendations:------- }------------------- --------------------------------------- ---------------------- -----•----------------------- •------------------------------ <br /> f <br /> ---------------------­------- A <br /> --------- ------ -------------------------------- ---------------------------- --------- ------------------------------•-------------- <br /> FINALINSPECTION BY:--------- ------ - ----- `----- . Date----------�------------------ ---------/--------------------•-------- <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 /> 4 <br /> ' GC-0_9AA - R-;-4 4 W_7160 C <br />