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Permit No. .-� <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) Date Issued __---/--S <br /> Application is hereby made to the San Joaquin Local Health District for a permit to consfiuct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> f <br /> ' j .f w ------------. --•---- ----- -- <br /> JOB ADDRESS AND LOCATION---------------------------------------------------'---=------------- ---------- -------*---T-1 <br /> ` - ..................................... <br /> ///� � Phone <br /> !� _ <br /> Owners Name-------- t <br /> •----•-----------•------•-•------ <br /> ---- �¢] <br /> Address----•------- <br /> _________ _ _ <br /> - - <br /> Contractor's Name____ --•--- Phone,- -'�-�-----�-- - <br /> � Motel Other ❑ <br /> Installation will serve: Residence Apartment Hou}e'❑ Commercial ❑ Trailer Court ❑ ❑ { <br /> Number of living units: ` Number of bedrooms �_ Number of baths ._/_ Lot size ----- �` ---------------------- I <br /> t - <br /> Water Supply: Public system'❑ Community system'❑m Private Depth to'Water Tabiea- ft. <br /> Character of soil to a depth of 3 feet:, Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No �New.Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if"Public sewer is available 6n200femme+) w I <br /> ., <br /> ----------- <br /> }i ank: Distance from nearest well__ ° -- ---Distance from foundation- .-_- '_.'.Materia----------- <br /> No. <br /> -_- ----.- <br /> No. of compartments__=_ -i-0-- -Size.-----•-------:-'------- -- --. Liquid depth----- -- ----- I Capacity.-- V+.1< <br /> tf -----••- <br /> p t well_ :---- Distance from foundation- �.-----_ _;Distance }o nearest lot line <br /> Dis osal eld: Distance from -------- <br /> ilea ;i--i- t Length of each line------- Width of°trench-_.?---�- ------ <br /> Number of lines-_---_- pp <br />,l Type of filter material_ Si�Co ✓�-Depth of filter material ---.- g---------srToa length------------------ I <br /> Total <br /> • <br /> c - <br /> w <br /> i Seepag I}: Distance to nearest wel►:_ d - ----=-Distance fr m #'iindation_.:- r __�-----.Distance to nearest of ane----------------- <br /> Number of pits-:- ------------Lining material_". ----Size:.Diameter__._ _ .��.---.Depth--- .- -----•---"-• " <br /> Cesspool' Distance from nearest.w.0------ __{--:._Distance from foundation--------------------Lining materialy----.-----------------.__----els <br /> -Li Liquid Capacity -------------gals. .� <br /> ❑ Size: Diameter--------------------- y "----".Depth--------------------- ------------------------ q P Y " <br /> a nearest building----------------- - <br /> „... , - <br /> Distance-from nearest well--''_..__"--- <br /> W, ---- <br /> Privy: �.' --------------------------------- <br /> . _. '. ----------------------------- is ------- <br /> -Distance from -=------------------ ----- <br /> ❑ Distance to no aresf-lot-line-­41-100:" -- -- -- , <br /> I: 4 e <br /> ----------- <br /> Remocl6ng and/or repairing (descnUe):_-- -_-._.- ,_____ -- <br /> i t- --- <br /> - <br /> -------------- <br /> - '-------- - ------- ---- _ with an o m oun <br /> I <br /> b ce that I have prepaired -his --------�----------- - ui <br /> --- - <br /> -- --- '+h S .! a u C �t <br /> I here y p p application and that the work will be done in accordance9 <br /> ordinances St to aws, and rules and regulations of the San Joaquin Local Health District. <br /> Owner and/or Contrac+or) <br /> (Signed).---. ------ -- <br /> 4 ------ <br /> -.. -------------- <br /> --=-----•-•-. :, } :.----Title)------ -- - -------------------------------- <br /> By: <br /> -------•---- : <br /> By:--------------- <br /> (Plo# plan, showing size 01110t, location of system in relat' n to wells, buildings, etc:�can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> -------- DATE----------------------------- - <br /> APPLICATION ACCEPTED BY----------------------------- ” <br /> � <br /> REVIEWEDBY------ -------------------- ----------------- <br /> BUILDING <br /> - -�----- <br /> -----------_---- ---- ------- = <br /> - - ----------- ---------------- DATE <br /> BUILDING PERMIT ISSUED-------------------------------------- ---•--- <br /> - - ----- ----- <br /> -----------"-------- --- --"-- DATE..-------=------- --- -�- • ---------------Al+erations and/or.recommendations----------------------- - <br /> -- -- ------------------•---------- <br /> ------------- --- ------------- <br /> -------- <br /> -----"----i. ............ -------------------------------- .--_---_-...-- <br /> •1 ---. ------------------------ <br /> - f - -_-" _ .-----• _--.-_-__-------------- .---------_ -. .--------_--_--- <br /> `1 fr <br /> --`�- � A -L-'.'_-./s'-l __..-. - _�^� _ - -"---- ------------------------ <br /> ---- <br /> --- - -- ------- _ ----._---_---•----------'_--_-_------ <br /> i is I <br /> .�------------ i _. - <br /> F... a <br /> D to_:- "- --------- --- <br /> FINAL INSPECTION BY:_.---_ ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 132 sycamore Street 814 North "C' Street <br /> 130 South American Street 300 West Oek Street Trac California <br /> Stockton, California <br /> Lodi, California ti Manteca, California Y� <br /> F <br /> ES-9-2 K4 Revised 1-57 F.P,CO. f a <br />