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i <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <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. /✓/{ ,f / f� <br /> JOB ADDRESS AND LOCATION--=-------- ------------ -------�`------- '_-.[-----C/l7----- -- -------------------------------------------------- <br /> -------------------------- <br /> Owner's Name____--__ ____ 1-'1v1AIG_ "� ,. ____ Phone__ j-7 <br /> --------------------------------------------- <br /> Address--------------- - GirGO'✓--✓ <br /> Contractor's Na'me_. g'G✓riff. / ------------------------------------------- Phone <br /> Installation will serve: Residence Apartment House E] Commercial ElTrailer Court E] Motel E] Other F] t <br /> Number of living units: 'R1 Number of bedrooms [ . Number of baths Lj� Lot size----------�O_X_ .tel --------------------- <br /> Water <br /> __________________Water Supply: Public system ❑ Community system F] Private f <br /> Characterkof soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe 2j Hardpan [:] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 ffjs i /� <br /> . . .J'0 - _. �----�v <br /> Septic Tank: Distance from nearest well_________________Distance fro�oundation_______ _________Material----- __________________-____r___________- <br /> No. of compartments--------.�___--------Capacity---;-__.l1A____._Size__ _�4_ _x__ _._Liquid depth----- ------------"_--. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__________________________________-' <br /> ❑ ;. Size: Diameter-------------------------------------Depth-------------_-_------------------------------------ <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> \ <br /> ❑ Distance to nearest lot line------------------------------------------------ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation_________________'--.Distance to nearest lot line______________-- <br /> ❑ Number of pits l--------------• ----Lining material-----------------------Size: Diameter h - <br /> -----------------------.Dept -------------------�t <br /> Disposal Field: Distance from nearest well ______.Distance from founds+ion________------------Distance to nearest lot line----------- <br /> Rol Number of lines!_______ ___-___ ________Length of each line---------- � _____Width of trench------- <br /> Type of filter material__"_L �IyDepth of filter matenal___-----l___-------- <br /> I <br /> Remodelingand/or repairing (describe)------------------------------------------------------------------------------------------------------------------------------•----------------- <br /> --------------------------------------------------------------- -------------------------------- ---__-__-------------------•-"------------•-------------------•--------------------------------------- <br /> -----------------------------•---------------- -------------=----------------------------------------------------------------------------------------------------------------•-------------------- ------------------------: ,.• <br /> r <br /> ------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> � <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County�;1 <br /> ordinances, State laws, nd rule's and regulations of the San Joaquin Local Health District. <br /> r <br /> (Signed)!—O(. t 4;?-��---- --���-0---�-- ---------------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By.:--- ----------------------------------�------- --------------------------------- -------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> . FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- ---------- r ------------ ---------------------------- DATE------- <br /> REVIEWEDBY----------------------------------------------------=-- ------ -------- ---------------------------------------------• DATE------ ----------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------------------—------ <br /> Alterationsand/or recommendations----------------------------------------------------------------------­-- -----------------•-------------"---------------------------------------------------- <br /> - --------------------- - ------------------------------- <br /> --- --------------------------------- <br /> --------------•---------------•-------------•-----------•----------------•----------------------------------------------------------------------------------- <br /> ----=--•-------------------------- --------------------• ---------- -------------------------------------- <br /> ---------------------r:----------- ------- -- ---------- -------­-------------------­----------------------------------------------------------- • ------- ------- <br /> PERMIT FILIAL INSPECTION BY----------------------------------------------- <br /> PERMIT No._'-cJ-__"5�--- ISSUED �-------- ---'T'---�'�--- ( <br /> rDate------------------------------------------------------ ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />