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f� <br /> fir` APPLICATION FOR SANITATION PERMIT <br /> Permit No. a__j(0--_r .-- <br /> (Complete in Duplicate) Issued <br /> __ -/-y_-__s <br /> Date / <br /> 1� <br /> Application is hereb"y made to the San Joaquin Local Health District for a permit to construct and install the wank herein described. <br /> This application is made in compliance with County Ordinanc"lo. 54Q� <br /> JOB ADDRESS A D LOCATIONS3�_.+�_ _'"-�-{,�- -�-�--��--- ----------------------------- ---------------- --- �--�------------------------------ <br /> Owner's <br /> - - ----------------------Owner's Name- ----- ------ ------ ------- -------------- ---------------------------------------- Phone-----""""~------------------- <br /> Address..-•-------- --- ---- ------------- - - -------------•---------==------------------------------------------------------------------------------------ <br /> Contractor's Name--- - -------- --------------- ------------------------------------------------------------------------------- Phone_-O -- ---- <br /> ----- <br /> - --------- <br /> Installation will serve: Residence ❑` Apartment House E] Commercial ❑ 7rai r Court ❑ Motel Oth r <br /> Q - _ _ ------------------- <br /> Water _: <br /> � Number of living units: _�"_ umber of bedrooms _--_ __. Number of baths --. ---- Lot size -__.--- -- <br /> Supply: Public system ['Community system '❑ Private ❑ Depth to Water Table -------- ft. <br /> t <br /> Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam Clay Loam El Clay ❑ Adobe Hardpan C]Previous Application Made: Yes El No New Construction: Yes No ❑ <br /> k TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public se er is available within 200 feet..)) <br /> Se tic ank: Distance from nearest well._ �istance fro foun aftion---- -(.1-- --__M fi ri (__------._-- <br /> --- - <br /> p 5 .T --- , y <br /> - ��-�t ----Liquid depth_--------- --=-----Capacity----�� <br /> No. of compartments---_---- _ _ _- �- -- -------- <br /> off I I <br /> Di4s os Field: Distance from near st We W - ___ .Distance from foundation-- __!-_ Distance to nearest lot lin -- �- <br /> P ! �£t i <br /> Number of lines--- _-_-- �, --- - _--Length of each line----_--__- p- Width of'trench--------- - - 4 <br /> Type of filter materi -_ �-�Depth of filter material____-1Q-----------Total length--------- {---_.--------_._•-..____- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------..___.Distance to nearest lot line----------------- %A <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------------------__---------_ <br /> Cesspool: Distance from nearest well-_-----Y---_-Distance,from,founda#.ion___________________ Lining material------------------------------------- I <br /> ❑ Size: Diameter----------------- --------------------Depth------------------------------------------------------Liquid Capacity----------------------------gals. 4 <br /> Privy: Distance from nearest well-------------------------------------------------Distance`from nearest building-_-----______----_-_____.----__-___.------ ► <br /> ❑ Distance to nearest lot line----- -------=------------------------------- ----------=-------=-------------------•------- --------------------------------------_- <br /> g an9 ( <br /> Remodeling d describe - .----------------------•-------------- = -------- -------------------- ----------------- <br /> /or repairing <br /> r <br /> --------- ------------•---------------------•-------------------------------------------------------------------------... =--- --•-- <br /> --------------------------- --------------------------------------------•-----------------------•-----------------------------------------------------•--------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, S laws, and rule and regulations of the Sd"n J,*aquin Local Health District. <br /> (Signed) '' . <br /> -----------------------------=-----------------------------(Owner and/or Contractor) <br /> �--Lw --- . 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 /> APPLICATION ACCEPTED BY-_-- ------------------------------------------------- <br /> - - -�------��-------- ---------------�-- ---------------------------- ---- DATE--- <br /> REVIEWED BY----------------------------------- ---- - ------- -------------------------- <br /> - <br /> DATE � ----------------------------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE---------- -e--------------------------------------------- <br /> Iterations and/or com endations- -- ----------- ----- - ---- <br /> - ^' ,__�. 4 'G .,t%• c 3 40---e—P------------------------ --- ---- <br /> -------------------------------=------------------------------------------------------------- <br /> w -------------------------- --------- -----------�--------------------- ------------------------------------------------------ -------•------ ----------------------------- <br /> = --- <br /> ---- ------------ Date----- �/_ <br /> ""• � .- <br /> M. ----- ` <br /> FINAL INSPECTION BY:-- -- f <br /> f " . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street a 100 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> r <br /> F ES--9-2M 8-51 Revised W-2400 <br />