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- y <br /> Permit No. <br /> APPLICATION FOR SANITATION PERMIT ----- _©_ <br /> (Complete in Duplicate) Date Issued Mev <br />'w 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 /> JOB ADDRESS AND,LOC TION �C�,_j�i/! /��] + --------------------------------------------------------------------- ----- <br /> Owner's Name._.`1°------/it- � !-K_1I- -r-- --------- --- ------------------ Phone--- <br /> ----,-- --------••-•------•---------- ------------------------ - - <br /> Address 'Ej7A.../ ---- _ ------------ --- -�'C-�---------------- ,�41C.LAA! -------� C�`----------------------------- <br /> Contractor's Name--------2� ----------------------------------- ---------------------------------------------- Phone------------------------------ <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ------ _ Number of bedrooms I---- Number of baths _1____ Lot size'___/�______�_��#�__ _____________________ <br /> Water Supply: Public system ❑ Community system '❑ Private ['Depth to Water Table j_" _ 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 5� New Construction: Yes ;9 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-_/4-4-...-___-___-_.Material/ ° _______________________ <br />" r No. of compartments_-__' __--_Size-Y__rX_- X_}�_f__._Liquid depth----- __Capacity <br /> Disposal Field: Distance from nearest well-.-�_7---------Distance from foundation___0__�____--_-_-Distance to nearest lot line___ <br /> Number of lines------------¢-____-- _--- �rr Length of Each line--------- <br /> i---�a------.Width of trench------ --w--------------------: <br /> Type of filter materiak__ _ TcfS.--Depth of filter material____A_-___--------Total length-__-----ice°� ---------------------- <br /> Seepage Pit: Distance to nearest well_________________ <br /> -__Distance from foundation--------------------Distance to nearest lot line__,______________ <br /> ❑ Number of pits----------------------Lining material-------------- ___Size: Diameter-----------------------Depth--------------------------------- <br /> 4-1 <br /> Cesspool: Distance from nearest well-------------_---Distance from foundation_._._____________-.Lining material_________-_-_-_--______-_______ ____. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity_,------------------------gals. <br /> _. <br /> _ .� <br /> .. �Priy�yc ; �D.istance.�fr-omanearest-well:=---*'��=-�"----_-' ---------------------Datance Trom nearest build ing-----------------------___..-------------- <br /> 0 Distance to nearest lot line---------------------------------------------------------- ---------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe)-------------------------------------------------------------------------------------------------------------------------------------------------------- W <br /> ------------------------------------------------------------------------•-----------;-------------------•-------------------------------------------•------------------------------------------------------------------- <br /> --------------------------------------- -------------------------------------------------------•----------- ----------------------•---•--------------------------------------------- --------------------- ------ <br /> -------------------- --------------------------------------------------------------------------------------•---- ------------------------------------------------------------•----------------------------------- "t <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, State I ws, and rulesjqj�n�degulafions of the San Joaquin Local Health District. ✓ <br /> _____________________ ___Owner and/or Contractor <br /> (Signed)------------ � -- - { / ) A <br /> By -----------------------------------------------------------------------------------------------------------------------------------(Title)--------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- -- -- - DATE ` y -* <br /> VSVItWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE.--- =_= ",---------------------------------- <br /> BUILDINGPERMIT ISSUED-----------------------------------------------:-------------- = ----------- ------------- -._ DATE <br /> Alterations and/or.xecommendatio4is:--------------------- ------------------------.---------------------------------------------------------------------------------------------------------------- <br /> ----- <br /> --------------------- --- ---------- <br /> ----------------P----------i°------------------------------------------------ <br /> -1�. .L..........&V <br /> FINAL INSPECTION BY-------------- Date ----- -------r-"---/------- ---------------------------- <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 851 Revised W-2160 <br />