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APPLICATION FOR SANITATION PERMIT Permit No. ---------- ------ <br /> (Complete in Duplicate) Date Issued ...-----------s- <br /> Ilk <br /> 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 CounOrdina o. 549, <br /> 10 --------*I-- <br /> JOB ADDRESS AND L ...... <br /> 0 C�/A ' ------- --- -- ------- ----- - ------ <br /> -------------------------------------------- <br /> Owner's Name-------------- --------- --------------- - ------------------------------------------------ Phone------------------------------------ <br /> I-A. <br /> Address-------------------------- .. .... —--------------------- <br /> ------------- ----------- <br /> �_- -Y - !�­ . 6 <br /> Contractor's Name----- __ _/ <br /> --------- ------- ------------ ------------ ---- Phone-- <br /> serve: �Resiclence Apartment House E]. Commercial railer Court 0 Motel F] Other E] <br /> Number of the ------- Lot�. -A-----------n. <br /> Number of living units: N ber of bedrooms __ ____ Num size <br /> Water Supply: Public system 4wCommunity syste -E] Private. Depth to Water Table7_L_>__ ft. <br /> Character of soil to a depth of.3 feet: Sel ESandy Loam Eay Loam EClay EAdobe <arcpan 0 <br /> Previous Application Madei,,Yes E] No Construction: Yes No F-I <br /> d <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No,'sepfic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic ank- Distance from nearest well____________.___Distance from foundation___________________Material-___________._____________.________--_-_______ <br /> 0. of_compartments-------__---------------Size----------------------------_---Liquid depth---------------------- ---Capacity----------------------- <br /> Disposal 'Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line____________..... <br /> Omber ofilines-----------------------------------Length of each line---------•--------------------Width of french------- ---------------------- <br /> er Total length----------------------------------------- <br /> ype OT filter materia]----------------------- h o'blal----- ---------- --- <br /> . . .........Distance to nearest lo e__ --------- <br /> Seepage I Disfance,to nearest well ------------ �Zispta ce fr ou afion---k120 <br /> Number of:pit's..-. ----Lining materi I ize: Diameter____.1<.1"r_" Depth-- <br /> :0 <br /> Cesspool: Distance from nearest w6ll------------------Distan nclation--------------------Lining material_____________________________________ <br /> ❑ <br /> Size: Diameter------------- ------------------------Depth---------------------------------- ----------------Liquid Capacity----------------•-----------gals. <br /> (A� <br /> Privy: Distance from nearest well________________ --------------------------- __Mstance from nearest building_____-..--_-_-___-____________-_______-. <br /> lot - I -- - - - - <br /> building------- -------------------------- --- -- <br /> ED;stance'f6hearest 'llne._`--'-----"'---- <br /> ------------------- <br /> ----- --- -- -------------------------------------- -­­---------------- ­ <br /> Remodeling and/or repairing (describe)------------------- <br /> ------------------ <br /> ---- ��__•,•_-___- <br /> -----------------I------------------ ---- *----- ------- ---------- ...... -------------------- ---------------------- <br /> ------------------------------------------------------------------- <br /> ----------------------------------------------------ie <br /> ------------------------------------ ----------------------- ---------------------------------- ----------------------- --------- ------------------------------------------------------------------------- <br /> -_ <br /> I hereby ie"ifif <br /> -_ j that [have prepared this application and hat-the work-will be done in accordance.with San Joaquin,Counf-y--. <br /> ordinances, State law p, and ruVl.,-san regula ions of the'San Joaquin Local Heal District. <br /> (Signed).... _____(!Q�w�-era.nd/ ir Contractor) <br /> --- --- ------- ------------ <br /> .. ....... ...... <br /> By--------��­ - ------ <br /> --------L--------------------------- -- ---------------------------------------------------------- (Tif le),. _I , <br /> ------------- <br /> ---------- <br /> I'lel.. .. ..i . ..Ifnt <br /> (Plot plan, showing size of lot, location of.sysfem in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------------------ ---- --- --- ------------------------------------------ DATE----------- <br /> ------------------ <br /> - --- ----------------------- ---- <br /> REVIEWED BY--------------------------------------------1_----------------- ---------------------------------- DATE--- ---------- ----------- <br /> BUILDING PERMIT ISSUED------1------------------------------------------------------------ --------------------------------- DATE---------- <br /> Alterations and/or recommendations:------------------------------- -------7-------------------------------------------------------------------- ------------------------------------ <br /> ----------------------------------------------------------------------------------------------------------------------------- ------I-. -----•------------ ----------------------------------- ---­--------------­-------- <br /> ----------I----------------------------------------------------------------------------------------------------------------------\---------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------•-------- <br /> - <br /> ------------------ <br /> ------------------------------------------------------- ---------------------I----------------------------------------------------------------- ----------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:- ----:,----------- ------5------------------------------ Date------. ---------- -------T-------r��--------------------------------- <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 /> E5-9-2M ; I Revised W-2100 <br />