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APPLICATION FOR SANITATION PERMIT Permit No. .....- <br /> (Complete in Duplicate) .7/ S11 <br /> Date Issued ...... <br /> plica ion i her y made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> T is application is made in compliance with County Ordinance No. 549. <br /> _0 <br /> JOB ADDRESS AND L A 0 . ....... . . . . ....... --------------------------- ---------------------------------- <br /> plica-lon � her y made to <br /> is an 1,c� <br /> 'on is made m compliance <br /> D LA� <br /> 0 ------ �tz ---------- <br /> Owner's Name-------- --------- -- - -------------"_ -7-7 <br /> ----------------------- ------------------------- ---- -- . <br /> Address------------------------------ --------------------- --------- ----- ----------- ----------04�7--------------------------------------------------------------- ------------------------------------- <br /> Contractor's Name-------- -------------------------------- -- ---- - --- --------- ----- --------------------------- Ph on��_ 957� <br /> Installation will serve: Residence Apartment House [] Commercial E] Trailer Court 0 Motel [-] Other E] <br /> Number of living units: Number of bedrooms Number of baths _/----- Lot size �---X_/2 0----------------------------- <br /> Water Supply: Public system Community system [_1 Private E] Depth to Water Table__ ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy Loam E] Clay Loam El Clay [__1 Aclobex Hardpan E] <br /> Previous Application Made: Yes El No K New Construction: Yes Ej No K <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: - Distance from nearest well_________________Distance from foundation--------------------Material----------------- ------------------------- <br /> 0J5)_(jS-riA& No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity--------- ---- -------- <br /> Disposal Field:ma Distance from nearest well_._.._____._....D�starce from foundation--------------------Distance to nearest lot line-----------__ <br /> E]Ax1Sf' Number of lines-------------- ------------------Length of each line------------------------------Width of trench------------------------_ <br /> Type <br /> rench-------------------------Type of filter material-------- ----------------Depth of filter material___.___-_.__.._______Total Total length------------------------------------------ <br /> It 9 <br /> Seepage Pit: Distance to nearest well, OZOj----�Distance f f clation--7-S---------Distance to nearest lot line—S----------- <br /> ft Ir <br /> Number of p;fs.--OP'�.. ---------Lining material--;6VO�MTO .'Size: Diameter__.1V13.......... Dep fh__�Zr-------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_.._---___.---__.__-___..___________. <br /> ------------------------------ <br /> El Size: Diameter----- --- - ------- - -------Depth------ -- ---------------------- - ---------- ---.-Liquid Capacity----------------------------gals. <br /> Privy: Distance from rearest well---------------------------------- -------- -----Distance from nearest building.____._.__.__.__________------------------ Q <br /> ❑ Distance <br /> uilding------------------------------------------ <br /> Distanceto nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):_._._____. -------------------------------------- <br /> --------------------------I------------------- <br /> -------------------------------I------ ---------------:'"-------- -------------------------------------------------- <br /> ------------------------------------------------------ ------- ---------- <br /> ----------- ------ <br /> -------------------------------------------------------- -- -------- --- ------ --------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I h v prepa ed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and u[es an regulations of the, an Joaquin Local Health District. <br /> (Signed)----------------------7-------2---- --------- _------------- --7- - --- -------- ---------- wrier and/or Contractor) <br /> I-------------------- �A <br /> --- --- -- ----- <br /> ers S. <br /> ---------------- <br /> By:------------------------- ------------ -- ­ -- --------- - -------- -A--------- -- -------{Title)------------ --- ---- - <br /> (Plot plan, showing size of lot, location of system in relation tow)s, buildings, etc., can be plat d n reverse side). <br /> .-FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- - ------------ --------- ----------------------------------------------------- DATE--------->--------------- --------------------------------- <br /> ---- -------- <br /> REVIEWEDBY------------------------------------------------- -- ----- --------------------------------------------------------------- DATE---- ---- _7-- ------------------------------------- <br /> BUILDING PERMIT ISSUED-----------------------------------13 - - --------- ---------------------------------------------------- DATE----- ---------------------------­ <br /> Alterations and/or recoTme dations: ------ --------------- ------------------------------------------------------------------------. ....... <br /> ------------ -----------------__------------------- <br /> ---------------------I ----1_�_ -- --- ----- ------- ------------------------------------ <br /> ------------ ------ ?----- --------------------------- <br /> ------------------- ------- ----- -------I.____ / --- ­-------------------------------- --------------------------- <br /> ------------------------- -- --- - ---------------------------------------------------------------------------I-----------\--------- ------------------------------------------------------------------------------ <br /> ------------------- ------ ---------------------------- ----------- ---------------------- ----- ----------------- ------------------------------------------ ---------------------------------- <br /> FINAL INSPECTION 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 /> E8­9-2m 145446 ATWODD 12-54 <br />