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r <br /> A?PLICATION FOR SANITATION PERMIT Permit No. _- �r-3'J`-___ <br /> (Complete in Duplicate) Y <br /> Date Issued __.__�a4�-� <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 Ordinan e No. 549. <br /> JOB ADDRESS AND LOCATION -_ --- (/<G - Viz'" ---------�---1 �. <br /> T--------� / , <br /> Owner's Name----�e '4' (/ ---------------- ------------------------------ ----------- Phone--•� � ------Cc=:u <br /> Address - g �'--=c' <br /> Contractor's Name_-__-__ __`__�J t t ____________ _ __ <br /> ------ Phone---2-- -•-ya <br /> Installation will serve: Residence ❑ Apartment House ❑ C mercial Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _...-___ N ber of bedrooms ________ Number of baths ______- Lot size ____3_--.�_x// G <br /> -- <br /> Water Supply: Public system Community 5yste E] private E] Depth to Wtter Table•3S 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 [!J-lo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet') <br /> tic arrk: Distance from nearest well__ ___________Distance from foundation____t__ -----------Material__________________.____..___-_______________. <br /> No. of compartments_;. <br /> _.-____ _Size__ <br /> ___________________ Liquid depth_________...___________-_C <br /> Capacity <br /> __ <br /> pfeld: Distance nearest well=_ = Da <br /> foundation'__ -----------Distance to nearest lot line_________________dy (� Numbeof Ines -_Length of each Ine . Width of french y or <br /> filter material---------________________Depth of filter material------j---s_----------Total length________-_________-____-____________-___ <br /> Seepa Pit: Distance to nearest well./1J-6__________-Distance from foundation--__ __-__.Distance to nearest lot line--,-/_,1-. <br /> Number of pits------/------------ Lining material_g;�u -.Size: Diameter-----3 8'_.'____..Depth_____a,Z-'_________________ <br /> Cesspool: Distance from nearest well_..,____ _Distance from foundation__i___-_.._._-___.Lining material-------------------------------------- <br /> ElSize: Diameter. '----------------Depth---- ------------------------------- ---------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from- nearest well"------------ ___ ____--------Distance frpm nearest building-------------.______-_-________-______- <br /> ❑ Distance to nearest lot line!----------+= , - --------- <br /> Remodeling <br /> ------=Remodeling and/or repairing (describe): --------- <br /> ----------N----==------==-----=----:-=-=------------------------•--------- -------------------------------------------------------- <br /> -------•---------•--------•-------------•------------•--------------------- �.- _ _----------------------------------•-----------•------•------------------------------------------------•- <br /> ---------------------•----•-------------- --------------------- ----•------------------------------•---------------------------------------------------------------------------------------•---------------- <br /> - ---------------------.- ,----------- -------------•---------------------------•------------------------------------------------•-----------------------------•----- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Counfy <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)--------- i� v G!-f�` •----------- �'= (Owner and/or Contractor) <br /> ------------------------ <br /> BY:------------------- -e'w -------------------- ------- Title <br /> (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------- ---- ------ ------------------------------------------ DATE---------- <br /> REVIEWED BY_ `! <br /> ------- DATE--------- ---------------------------------- <br /> BUILDINGPERMIT ISSUED------------- - --------------------------------- --------------------------------_------------ DATE------------------------- <br /> Alterations and/or recommendations-----------------------------------------------------------------•--•-----------------------------------------------•--------- <br /> -------------------•-------------------------- -------------------------_----------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------- ----------------------------------------------•-----------••---•---------•--------•---------------•--------------------•------------------- <br /> •--•-•-------------•----- --------------------- •--------------------------------- ------------------------•------------------ -------•---••---------••-•-------•----•----•-•---- -•---------•------•------------- <br /> --------------------------------------------------- ---- _•---- <br /> ----------------------------------------------- ---------------------- <br /> FINAL INSPECTION BY:____ `/ G <br /> --tom--- ---•------ ---�r.�.'�'----•--------------- Date--- -------- ----�-•'f-�-`-�-----••-----------•-------•------•--------------•- <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 /> ES-9-2M : Revised W-2100 <br />