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APPLICATION FOR SANITATION PERMIT <br /> Permit No. .3--------- ----- <br /> (Complete in Duplicate) Date Issued --- <br /> Application 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. <br /> ---------- <br /> JOB ADDRESS AND LOCATION-------•------ 3 t�a-------FI-------W-�_ <br /> ---- -----------OIly <br /> wner's Name-------------------------------------------- <br /> *1ma.5--------------=------ ------------ -------- <br /> Address--------•----------------------•------------------------------- ----•----------•--------------------•--- <br /> --------- - - -- <br /> --------------- Phone----------------------------------- <br /> Contractor's Name-------•------------------------------- - ---- • ---- -- ---------•--------- ---------- ---------------- --- <br /> - - - <br /> Installation will serve: Residence 4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I <br /> Number of living units: ________ Number of bedrooms Number of baths ________ Lot size --------- __n-- ----0 0-0----------------- --------- <br /> Water Supply: Public system [I Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> 1 <br /> Character of soil to a depth of 3 feet: Sand E] Gravel ElSandy Loam ❑ Clay Loam CD Clay E] Adobe ❑ Hardpan [I <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ <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 /> ❑ No. of compartments--------------------------Size------•--------------------- ---Liquid depth---.'---------------------Capacity--------------- ------- <br />' ____________________Distance to nearest lot line----------------- <br /> Disposal Field: Distance from nearest well_______---_____.Distance from foundation <br /> 1 ❑ Number of lines-----------------------------------Length of each line---------------------------'--.Width of trench_---------------------------------- <br /> I Type of filter material-------------------------Depth of filter material----------------- '----Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well.____._______________Distance from foundation___________________Distance to nearest lot line-----_.________ <br /> ❑ Depth--------------------------------- <br /> Number of pits----------------------Lifting material-----------------------Size: Diameter <br /> Distance from nearest well-________________Distance from foundation------------------ Lining material_-_-_________--_____._____-.__.___--_ _ J <br /> ❑ Size: Diameter--------------------------- ------ .............................................. <br /> Distance from nearest building----------/0------------------------- <br /> Distance to nearest lot line------ -- ---------- -------- ------------ ---------------------------•----- <br /> f. <br /> Remodeling and/or repairing (describe)_______________________________________________________ _________ <br /> --------------------- <br /> n ---------------------------------------------- <br /> A-1--- --------------;--------------------------------------------------------- -------- --- �. <br /> ---------- <br /> o/ <br /> i------ <br /> - -- -------•-------------------------------------••----------------•-==------------------------------------------------------- <br /> �l <br /> I hereby certify that Lheve prepared this application and that the work will be done in accordance with San Joaquin Dunt <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Owner and/or Contractor) <br /> (Signed);------------------------------------------------ --- --------------------- ---------------- -------------------------------------------------- <br /> + ,(' " _-+ --------------------------------------------(Title)--------------------------------------------------------------- <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 /> DATE------------ - -- -� ------------------ <br /> APPLICATION ACCEPTED BY------------------------------ a5 oti - <br /> REVIEWED By------------------------------------------------------------------------------------------------------- <br /> -- ------. DATE-- --- ------------------ --------------------------------- <br /> REVIEWED <br /> ------------------------------ <br /> --------------------- --------------- DATE---�--------------------------- -- ---------------------- <br /> BUILDINGPERMIT ISSUED----------------------- -------------- ------------------------- <br /> and/or commendations: _ ----------------------------------------- <br /> r, r -------- --------------------------------------------------- <br /> Alterations�—. � --------------- — w <br /> — �f•-- ----------- ---------------•--------•------ <br /> ---------- <br /> --------------------------------- <br /> ----------- <br /> ----- <br /> --._ �_. "?_ 0-s.' = ,-mac`'Q <br /> • ', <br /> - - <br /> - - <br /> +'4J7. - - ----------------------- -------- -------- <br /> FINALINSPECTION BY----------------------------------------------------------------- Date-- ---------- ------------ ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> 130 South American Street TracCalifornia <br /> Stockton, California Lodi, California Manteca, California y <br /> FS-9-2M 1e-52 Raised W-2100 <br />