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Permit No.�D-�-=�--- <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) Date Issued _ .-�'---,!__------ <br /> Ap ication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work her described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION---------- - - - ---'�` <br /> Owner's Name------------------------------------------n ` -� <br /> 1� 4r -I� <br /> - ---------------------------- ------------- <br /> Address--------------------------------------------- <br /> ------------- Phone = <br /> a - -��� <br /> Contractor's -Name----------------------------------- <br /> Installation will serve: Residence 2—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [3 Other ❑ <br /> '"'�,. rr <br /> Number of baths -- _---_ Lot size ----- ---r-r. y ------------ <br /> Number of living <br /> units: __..I" Number of bedrooms -._ I 4 <br /> Water Supply: Public system ?4-Community system ❑ Private ❑ Depth to Wates Table ----------ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ElSandy Loam ElClay LoaI] Clay E] Adobes Hardpan E] <br /> Previous Application Made: Yes ❑ No�- New Construction: Yes No �a.�•-- d <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 44 <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' E <br /> Septic Tank: Distance from nearest well..-"-----_....-..Distance from foundation-------------- � <br /> 171 o. of compartments. - <br /> Size-------------------- ------•---Liquid depth--------------------------Capacity--..--.---- Xj <br /> tg ,� <br /> Disposal Field: Distance from nearest well- __ Ql'1A-�Distance from foundation.__... Distance to nearest lot line.... <br /> Number of lines-------- --j�-----.-----Length of each line----p ,_ _.-'---------Width of trench._ ---- -----------------" <br /> Type of filter material-----_,"R113 ...Depth of filter material._-_....1.�!......Total length--......_�-V--^--------------------- <br /> Seepage Pit: Distance to neares+ well...-.-_...-__.�-._Distance from foundation....................Distance to nearest lot line___...--....-____ <br /> ❑ Number of pits----- t-------- ------Lining material ------"Size: Diameter Depth (� <br /> Cesspool: Distance from nearest well----------------1.Distance from foundation'..-------_-----...Lining material-..-_._.-..------------------" aIs. i <br /> ❑ Size: ------------------•-----De th-------------------------- ----------------------- 'Liquid Capacity---------------------------9 <br /> Diameter-_....- __'__ p 1 <br /> Privy: Distance from nearest well------------------------------------------------Distance from nearest building-----__....------------------ -"--------- . <br /> #r ❑ Distance to nearest lot line- -=-------- -'----------------------- ------------- <br /> --------- - - - <br /> ---------�!-- <br /> �k --7- <br /> --- <br />� Remodelin--g and/or rep--airing (describe:. � -------- - <br /> ---------------- <br /> --- <br /> --- <br /> -- <br /> ---- <br /> ---- <br /> --iI---.. <br /> -. <br /> ----------I-------- <br /> ---------------------------------------- <br /> -------------- --------------------- <br /> ------------------------•------------------------------------------------- <br /> -- <br /> -- <br /> ------------- <br /> --------------------------------- <br /> - --------- -- ------- ------ ----- -- - ------ <br /> I hereby certify that repared this application and hat the work ill be done.in accordance with San Joaquin County <br /> ordinances, State laws, and rules an regulations of the San J quip Local ealth District. <br /> [Signed) -- --------- ---------}-- - -------------------------------:­------- t r►Contractor)C <br /> --- ---- ---- -- <br /> (Title)"-. .liter <br /> (Plot plan, showing size of lot, location of sys n relatio -to wells, buil ngs, etc., can be placed on reverse side). <br /> Fil, R DEPARTMENT USE ONLY .. ; <br /> ----------- DATE----- --------------- <br /> APPLICATION ACCEOTED BY..-- <br /> DATE------------------------------- ---------------------------- <br /> REVIEWEDBY------------------------------------------- -L-------------------------------------------------------=--•----- <br /> BUILDINGPERMIT ISSUED----------------------•----------------------•------------------- ----------------------------------- DATE------------------------------ <br /> Alterations <br /> -----•--- ---------------- -Alterations and/or recommendations:----------------------------------------------­--------------- •-------------- <br /> ------------- <br /> ---------------------------- -----------------------------•---------- <br /> --------------------------------- <br /> ----------- - <br /> -------------------------------------------------------- <br /> Z f` r! Date------------------ -- ------------- <br /> FINAL INSPECTION BY:-----A <br /> 1.--------- r <br /> >// <br /> - --------- ---- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 132 Sycamore Street 814 North "C" Street <br /> 130 South American Street 300 West Oak Street Trac California <br /> Stockton, California Lodi, California Manteca, California y <br /> ES-9-2M 10-52 Revised W-2100 - <br />