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APPLICATION FOR SANITATION PERMIT Permit No. ......,7YZ------- <br /> (Complete in Duplicate) 41/ <br /> Date Issued __-----/D�----- <br /> A <br /> - <br /> Applica4-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 �i Ordinance No. 5 <br /> JOB ADDRESS AND .......... <br /> ------- - <br /> I 109ATI0 .. I � ` ------ <br /> Owner's Name �- ------ - = - ------- ------- Phone---------------------------- <br /> Address------------_---•----- -- ---- -----------•---------------------------------------------------------------------------------------- -v..--- <br /> Contractor's Name."--- ; Phon <br /> - --- ------ --------- - -------•------------ -- -------------- ---- <br /> - <br /> Installation will serve: Residence ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -- ---- Number of bedrooms�.- Number of baths _/---- Lot size ----e v----.- .--�.-- -------_-__------- <br /> Water Supply: Public system itmw@MMunity system ❑ Private ❑ Depth to Water Table AOIt. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ <br /> Previous Application Made: Yes ❑ No �"'� Construction: Yes <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> r ` <br /> Septic Tank: Distance from nearest w•ell�_Distance from foundation_---��--"-_-Material_-. -- '-. -.___ <br /> --- ----- <br /> Sizel Liquid depth- - Capacity---- 1 <br /> pl- ,� No. of compartments----- - ----- -- <br /> Ra + <br /> Disposal Field: Distance from nearest we1L,0p%o6w*mw.Distance from founda - -f!_!..Distance tion--__ � Distance to nearest of line----J---------- <br /> Number of lines--------- __-------Length of each line---- ---- ---------Width of trench----- �.-------------------- <br /> - <br /> -----------_-- <br /> Type of filter material-_-,�_�-�__--Depth of filter material----.- .. �� Total length-- -._---_--__.---..---- <br /> Seep ge Pit: Distance to nearest weli�_ Distance m fou dation---.-r.....Distance to nearest 440 <br /> Number of pits....../-------------Lining material-_--41:v_-_-,d4_.Size: Diameter.��f..........Dept' _.,ZQ._-___-_---------� <br /> Cesspool: Distance from nearest well---------------:-Distance from foundation--------------------Lining material--- --------------- --- _-f -- <br /> Size: Diameter Y Depth ----------------------------Liquid Capacity -9as. <br /> Privy❑•. Distance from nearest well---------------------------------------..........Distance from nearest building ----_---------.------ G\ <br /> i <br /> ❑ Distance to nearest lot line-----------------------------•------------------•---------------------- ------------------------- --- ---------------------------•--- <br /> ---� <br /> Remodelingand/or repairing (describe)---------- --------------------------------- -----------------------------------------------------•-----------•--••-----•-•------------------------------- <br /> ---------­-­------------------------­­----------------------------- <br /> ----------------------------------------------------•--•--•----••--•------•-------------_----------- -•------------------••----- -----------------------•-------------------------------------------------------------------------------- <br /> -----------------------------------------------•----------------------•----...------------------------•----•----------•--------•------------------- --- <br /> ---------------------------------- -------------------------------•---•----•------------"•----------=------------------• ---------------------••--------------------------•-----•---------•-------------------------------- t{` <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, S to laws, and les and regulations of the San Joaquin Local Health District. <br /> r� <br /> (Signed) _--------(9waor..wvd?41P Contractor) <br /> B -------- ------•-- - (Title)---------------------------------------------------------------- <br /> Y --_--- - - --- •--� ---------- <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 /> REVIEWEDBY------------------------- ------------- ------ ------ -- ---------- -I------------------------------------------ DATE-------------\,-1------•------------------------•---•--- <br /> BUILDINGPERMIT ISSUED---------- •---------------------- ----- ---- DATE--------------- ---- -------------...------...----•---• <br /> Alte ation and/or rec mmendations: - ------ : -- <br /> . <br /> - -. --- - -- <br /> j'- -'`�a--`✓�„--- ---- <br /> --� -�� --------------------- ---------------------------------- •----•-------------------- <br /> ------ ------------------"-"-_- - -- .----- --- ._---. - ------------i- -._- _-.-_--------_.'--- --------_f.-' .------- --- <br /> -------------- - - <br /> -- -- -------- - -- ---- --- - --- ---- <br /> FINALINSPECTION BY------- ------------------------------------'----------------- . R Date--- ------------------------------------ ----------"----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street B!4 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 145446 ATWOOD 12-54 ' <br />