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APPLICATION POR SANITATION PERMIT Permit No. -----r.... • <br /> (Complete in Duplicate) r <br /> ! Date Issued _-- <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 County Ordinance No. .549 s <br /> qq ►-7 e <br /> JOB ADDRESS AND OCATION _:_J. --_/- = --------------------- -- -------------------------------- <br /> ��..�,�-�� ----11 _ . I <br /> Owner's Name _. on _ <br /> - --------- — - -----------------------------••--------a•---G•-------- <br /> ----------- <br /> Address-----------• - --- - ------ nelZ <br /> -----Contractor's Name = b <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial El Trailer Court 9 Motel ❑. Other ❑ <br /> Number of living units: ___:---- Number of bedrooms -------- Number of baths --------- Lot size ----____�� -------------------- <br /> Water Supply: Public system ❑ Communify system ❑ Private R Depth to Water Table ft: <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand;,Loam ❑ Clay Loam El Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: i <br /> (No septic tank or cesspool permitted if public sewer is available within 200 <br /> op Tank: Distance from nearest well-_-__-_----_---Distance from foundation-------------------..Material-------------------------------------------- <br /> ..... <br /> No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-•-----------.---------- <br /> bis ial s ield: Distance from nearest well-----------------Distance from foundation--------------'.:---Distance to nearest lot line---_-_--_--_----- <br /> j Number of lines----------------------------- -----Length of each line------_------------------_----Width of trench------------------:---------------- <br /> `l <br /> Type of filter material------------------r - -Depth of filter material-----------------------Total length--------.-_._.---------------------------- <br /> Seepage Pit: ' Distance to nearest well__1a�__._�_----_Diisfance from foundation _________________Distance to nearest line_._______________ <br /> Number of pits---_--/----------�__Lini lgmaterial__ ti/)_�_�cZ-?- £_41ze: Diameter___.--3 ....--------Depth... 34_11____._-- <br /> Distance from nearest we'L_:__ :______Disfance fr-om,foundationl_________________Lining material-------------------------------------- <br /> Cesspool: <br /> ❑ ; ' -*- i !'t--- - /- 1 <br /> Size: Diameter___.____-------------------- ---De th________ __..-_ __ Liquid Ca-pacifygals. <br /> t f' i <br /> Privy: Disfance from nearest well__'-..----- >._=--------------------------------Distance from in building----------------------------------------- <br /> ❑ Distance to nearest{lot line ""- ---- : _ � - . '._....,. - --------------------------------------- <br /> ------------- ' <br /> - <br /> I- ---------- ------- - - ---------------------------------- ----------------------------------r---------- <br /> Remodeling and/or-repairing [describe):___.______'__ <br /> -------------------•------------------'----------------------------------- ----------------------------------------------- --------------------k-------------------------------------- <br /> -- <br /> -------------I--------------------------------------,--------------------------•-•----•------------------------------------------- ---------------------------------------------------------------------- <br /> - t f <br /> 1 hereby certify that I have prepared this application and.that the work will,be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> 3 <br /> Contractor) <br /> [Signed}... i ...- ----------------------------- --------------------- {Owner and/or on ctor] <br /> 1 , <br /> = ----- Title----.- _ <br /> BY� (Title) ---=---------- <br /> (Plot plan, showing size of lot, locati n of system in relation to wells, buildings, etc., can.be placed on reverse side). <br /> a i <br /> FOR_DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- ------------------•z -- 1 -------------------------------------------- <br /> DATE-------------- - ----------------- <br /> REVIEWEDBY--------------------------------------- ---------- --------------------------------------- DATE----------------•--•-------------- ---------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------- --------- -----------------------------------------------------... DATE----------- ------------ -------------------------­---•----- <br /> Alterationsand/or recommendations----------- --------- ------------ ------------------------------------------------- ------------------_-- ....................................... <br /> k <br /> ---------------------------------------.-------------------------------------------------------------------------------------_.------------------------------------------.-----.----------------------------------------------- <br /> --------------------------------------------------------------------------------------------- <br /> --------------------------------- ------------------------------------- <br /> FINAL INSPECTION BY:--- -- - - �- - <br /> -- -------- -------------- ate--'=--------=------- ------------=- --- ---------- -------------------- <br /> ,�1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES---9-2M . Revised W-4100 <br />