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1 APPLICATION FOR SANITATION PERMIT Permit No. ........................ <br /> (Complete in Duplicafe) <br /> �• �' Date Issued 31).7/� � <br /> lica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, <br /> Thiapplication is-made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION--------------- <br /> W,Owner's Name--------------`�--f_�sd.r — . --it.hM-L -------- Phone--- -_ _ 777 "------------ <br /> Address------ '4 - ..�.../ 4" t' i <br /> ---------------•--------------------•-------------------....---• --•--...---•--------------------•------------ <br /> 1 - <br /> Contractor's Name-------------- © !'—-------------------------------------------------- --------------------------------------------- Phone------------------------------------ <br /> Installation <br /> -----_------------ <br /> E <br /> Installation will serve: Residence+ , Apartment House [I Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: --- --- Number of bedrooms .j____-. Number of baths_______ Lot size -_______6Q-X---`?�----------------------- <br /> Water Supply: Public,system "Community system .❑ Private ❑ Depth to Water Table'':--:--_ <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 UL New Construction: Yes W No;❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: s <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest we}i_ 4`---_s_Distan from fou dation--------------------MateriaL__ P ------- <br /> - � <br /> +��------Li Liquid depth 1N <br /> No.of'compartments _ Size G p. --------_.Capacity ��' <br /> + ` <br /> Disposal Field: Distance from nearest well-�Jra______ Distance from foundatioZ_Q__-_-_Distance to nearest lot line_________________ <br /> .;,:„�-`Number of.lines-_-----_�-------------------Length of.each line------------v Width of trench.- _3 --------------------- <br /> T <br /> -------------------- Q <br /> Type of filter material___ _ ' �h__Depth of filter material____________________Total' length___.___.�_____________________________ <br /> Seepage Pit: Distance to nearest well-._.___:_ _;-_._____-Distance from foundation:__. .Distance to'nearest lot line----------------- <br /> ❑ Number of-pits------- --------------Lining material---_-------------------Size: Diameter--- ---••---------------Depth----------------------------- <br /> Cesspool: Distance from nearest well_____--.--"_ _46istance.from,foundation____________________Lining material-_.__--_____-_-_____-___________-. <br /> ❑ Size: Diameter------- =----------------------------Depth----;----------------------------------------------7-=----------Liquid Capacity- --------------------------gals. � <br /> Privy:, Distance from nearest well-------------------------------------------------Distance from nearest building---------------------_-------------------- <br /> `-Distance to nearest:lot..line-------------------------------- " ' - "' <br /> Remodeling and/or repairing- (describe):--------- ----------------=------=-------------=----- --------------------------=--------- ---------------•=-----------------•--•----------------- <br /> R _ - <br /> ---•------------------------------`- ------------------•=----------•--------------------,----------•--.._.--- .. •---•...-------•--------•----..._--------------------------•--------------------------------------- <br /> t <br /> -------------------------- ----I- <br /> ---------------------------------------- - -------- ----------------- <br /> ------------------------------ <br /> --------------------------------------------------------------------------------- <br /> 1'hereby -- <br /> certify that I have prepared this application and that the work will-be done in accordance with San Joaquin County <br /> ordinances, Stafe laws!-and rules and regulations of the San Joaquin-Local Health District. <br /> I <br /> Signed(( 9 s )--------41 - - - - ---- -------T -------- ------- -- .-r--- ------ -------------------------------------------------------------_------(Owner and/or Contractor) <br /> Y• - --=---=------------------------=-------------------•----(Title)...-----•------------------------------------------------------ <br /> (Plot plan; showing size of lot, location of system in'relafion to wells, buildings,*efc:; can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY 1 <br /> APPLICATION ACCEPTEb BY r .._..--• --- DATE --- <br /> . .......................... <br /> BY-----------------------==-------------- --' ------- DATE----- ------------- ---------------------------------- <br /> r _ <br /> PERMIT ISSUED---------------------------------------------------------------- ---=------------------------------._ DATE-•------------------------ <br /> --------------------------------- <br /> Alterationsand reco_mmenda.tions:- ---------------------------- -------------------------------- --------=-----------•---------------=----- --• -----------------=------ ---- <br /> t , <br /> -----•---- ------------------------------------=---------------------------------------------------------------------------------------------------------------------•--.-----------------------------------------••--------- <br /> ----------=------------------------ ----- ------------------A------- ------------ -------------------------------------------------------- ----------------- ------------------------------------------------- <br /> FINAL INSPECTION, BY:. __ - ------ -:_ _ _�__-_ 1' --------=---- Date.-:------ ---g- - <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 Revised W-2100 <br />