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APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------------ <br /> (Complete in Duplicate) -� <br /> 1u Date issued ------ <br /> t <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Qrdinance No. 54f4A <br /> . <br /> JOB ADDRESS AND L ATION----_-_- <br /> Owner's Name Phone-- 4 - <br /> - <br />,..,, <br /> Address <br /> --- ---------- -------------------------------------------------------------------------•­-------------------- ------•-----....----------------------------- <br /> Contractor's Name------------- ----------------- Phone----------------------------------- <br /> Installation will serve: Residence 93-- partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: J--- Number of bedrooms - Number of baths _ Lot size -_ ------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table/ _ ft. <br /> Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No Er"-New Construction: Yes I0`�4o ❑ FHA/VA: Yes P^ No ❑ <br /> -TYPE OF INSTALLATION AND SPECIFICATIONS: - <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> s <br /> Septic Tank: Distance'�from 'nearest well_ ___ _ Distance from foundation_-- ____----. <br /> p �`�' �,�------.Material_-- ____ _ <br /> I No. of compartments--. ------------ ---Size- --- ---_-_Liquid depth--- r P y-- � <br /> Ca acit _-__-._ <br /> Disposal Field: Distance from nearest welL_ _' Distance from foundation---`' -----.--.Distance to nearest lot line---h, <br /> - <br /> [i Number of lines___--._.ot---- -------------= Length of each line____ - __________.Width of french-----2-�./--------_------ <br /> Typ of #filter materia e Depth of filter material----.AP"'------Total length_--.-- Z-----_--_________________ <br /> Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line----_-----.-----_ <br /> ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------. <br /> ❑ ; Size: Diameterk------.------------------:------------Depth----------------------------------------------------Liquid Capacity----------------------------gals <br /> . <br /> Privy: �' Distance from nearest well-------------------------------------------------Distance from nearest building-. _----_--------_.------_---. <br /> ❑ Distance- to-nearest, lot line -------------------------------------------------------------------------------- <br /> - --- - -- --- -- - <br /> Remodelin and/or repairing describe :-----_---.- <br /> ---------- <br /> J. <br /> 4_0� <br /> ----------------------------------=----------------------- -------------•-----=----------------------------------------------------------•--------------------------------------• --------------------------------------- <br /> ----------------- <br /> ------------------------------------- -------------------------------------------------- ---------------- <br /> -------------------------------------•---------------------------------•----------------------------------------------------------------------------------------------------------•----------------------------------- <br /> I hereby certify that I have'prepared+his application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, a rules and regulations of the San Joaquin Local Health District. 1 <br /> (Si ned <br /> g ) - ------ ---- -- ----- -- or Contractor) <br /> By'- - <br /> --------------------------------------------- -- --------- - ------ (Title) + ' <br /> (Plot plan, showing size of lot, locati of systemfin relation to wells, buildings, etc., can be placed on reverse side). <br /> hl <br /> _FOR DEPARTMENT USE ONLY 1-7 <br /> APPLICATION ACCEPTED BY------- s '„ ----------------------------------- ---------------- DATE---------- -__b___-5 ---------------------- <br /> REVIEWED <br /> -- -------------------------- <br /> REVIEWEDBY------------------------------------------------ ------------------ -----------------------------------•-------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ <br /> Alterations and/or -recommendations------------------------------------------------ -----•-----------------------------------•-----•-••----------------• • • <br /> ----------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------- <br /> -------------------------------------------------------------- ------ ------ ---- --------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY------ ------- -- Date -7-x----- _�---------------------------------------------•--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American:Sfreet• -300•W.es3f�Oak Street ti 132 Sycamore Street ' 814 North "C" Street <br /> Stockton, California Lodi, California t v Manteca, California' ' Tracy, California <br /> ES-9-2M Revised 1.57 F.P.CO. <br />