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APPLICATION FOR SANITATION PERMIT Permit No. <br /> Ie.4rJ Complete in Duplicate) <br /> Date Issued77+ e ",. <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct and install he work herein described. <br /> tis application is made in compliance with County Ordinance N 549. <br /> JOB ADDRESS AND. �N... ,1 ' <br /> 4 <br /> -""" -_ ----- -- <br /> -- -------- ---- <br /> --------------------- <br /> Owner's Name. -- ------------ --------T------ --------------------- <br /> "d <br /> ---------------- Phone__ ----- <br /> Address - -- -------- --------------- <br /> Contractor's Name -------;.;A------ -- -- - ­ >------------------ ------------------------------------ <br /> Installation <br /> -----installation will serve: Residenc Apartmen ouse [❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I <br /> Number of living units: __/--._ Number of bedrooms Number of baths ___ Lot size ___,.moo / 4------------------ <br /> Water Supply: Public ysl&nX Community system ❑ Private ❑ Depth to Water,Tablo ft. I <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ CIa oam ❑ Clay ❑ Ado b Hardpan ❑ <br /> Previous Application Made: Yes ❑ W0 New Construction: Yes ❑ N '( !A <br /> TYPE OF INSTALLATION AND SPE (FICA ]ONS: J <br /> � <br /> (No s tic tank or cesspool permitted f public sewer is a( �P ' <br /> P P � P va 1qWs_withirn 200 feet:) <br /> Septic Tank: Distance from nearest wall-----------------Distance from foundation__::-___t-----------Material <br /> ell' __.____________.._____ <br /> G No. of compartments------ ------Size------- I ' Liquid,dbpth------ Capacity a <br /> ------- - -------- - <br /> Disposal Field Distance from nearest well.___...____-..-Distance from foundation--------------------Distance to nearest lot line___ _.__._-_____ <br /> i"41Number of lines----------------- ----------------Length of �ine----- -------Width of trench <br /> Type of fitter material---------------------------------Dep#h of�I'l�er material-----"-'------ -�----Total length---------------------------------- -Seepage Pit. Distance to nearesf w II-f2'!.�{ -Distance fr foun tion_ A ----------Distance to nearest lot line__ <br /> - ------------ <br /> Number of pits________ _________Linin materia - _ _. ize: piameterDepth_--.C, .- ; <br /> - ----------------- <br /> Cesspool: Distance from nearest well_________ _______Distance from foundation--------------------Lining material ___________=-------------------------- <br /> El <br /> Size: Diameter-------------- ----- ------ ---.Depth----------------------------------- <br /> ---------------Liquid Capacity----------------------------gals. <br /> Privy;i„_, ,� _ Distance from_Weare t well______._ ------- Distance from nearest building---- <br /> Distance to nearest fof line----- <br /> Remodeling and/or repairing (describe)i_____.__.__ _ <br /> I <br /> -------------------•----------•--------------------------- <br /> i <br /> Y ••------------------- <br /> -------------------- ----------------------------------•---------••----------------- ------------------------•-----------------------------------------------------------------••----------------------------------I .... <br /> I hereby certify that I have prepared this appli;ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, StateI , and ru regulation the San Joaquin Local Health District. <br /> F <br /> (Signed)---------- --------------- '" 'r--~ <br /> ;. caner a o or <br /> By:------- ;---- --- A (Ti 'r ct-�� <br /> or ntra <br /> tl _ <br /> (Plot plan, showing size t, location of stem in relation to wells, buildings, etc., can be d on reverse si e). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__. i DATE------------------ --- - -- - - - - - - <br /> - <br /> --------- ----------------------- <br /> REVIEWED BY---------------------- ---- DATE.-- <br /> -------------------------------------------------------------------------------------------------------------------- <br /> - ---------------------- <br /> BUILDING PERMIT ISSUED ... w -� ---------------------------------------------------- DATE-- <br /> Alterations and/or recommendations:._.____-- -- _ _ _ ` <br /> -------------------------------------------- <br /> -------------------------------------------- <br /> --------------------•------.-- <br /> ---------------------------------------------------------------- <br /> ------------------------f-t- <br /> FINAL INSPEGTION BY__________________--------------------------------- ---------- Date--------------�- ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American St. r 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> 9-2M D 52 Revised W-2100 <br />