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I <br /> 1� APPLICATION FOR SANITATION PERMIT Pgrmit Normo........ <br /> ,. <br /> i• •(Complete in.Duplicate) y Date Issue <br /> Applica4-ion is hereby made to the San IJoaquin 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. 549.1 <br /> t 5 <br /> JOB ADDRESS AND 'LOCATION-------------- G__ ]rC?_.1 <br /> Owner's Name----------------•---- -,A------•s x r = 1 Phone <br /> Address =' -------------------------- --•------------- = = ` <br /> ------------------------------------------------------------------ <br /> Contractor's Name---= -----------------------------CI ti�'Y ' -= = -=== ------------------------------: Phone <br /> Installation will serve: �Residen ❑ Apartment House ❑ Commercial',❑, �Trailer Court Motel E] Other E] <br /> I , D <br /> I ; Number of living unit : 6 __ Number of bedrooms -------- Number of baths ________ Lot size _____- -Q_________ ____ '+ _________-.__ <br /> Water Supply: 'Public system X Community system ❑ Private ❑ Depth to Water Table -------- 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 FT New Construction:_.Yes )6• No ❑. I 1 <br /> TYPE OF INSTALLATION AND S'P'ECIFICATIONS: r <br /> I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 <br /> Sep ic'Tank: -iDistance from nearest well-----------------Distance from foundation_ __ -------.Material________I-----------___..____._-_______________ <br /> r :No. of compartments--------------- -- ----:Size--•------------- :- -Liquid depth ---- --- -.--Capacity-------------------- <br /> Disposal ' ield: Distance from nearest well____VD__.a.Distance from foundation------- _/�1__ _____-Distance to nearest lot line- 1. {, <br /> Number of lines-------,------j-------- ---------- <br /> Length of each line--------�_ -1-----------.Width of trench----------7, ------------------- <br /> Type of filter material_____-Ap-------------Depth of filter material-, -_/./_f--------Total length_____________ Q_-_________.____ <br /> Seepage Pit: Distance to nearest well______________________Distance from•foundation_._.................Distange to nearest lot line____=-._________ <br /> ❑ Number of pits.......}--------------Lining material-----------------------.Size: Diameter------------------------Depth---------------------------------- <br /> Cesspool: Distance from nearest we11-----------------Distance from foundation--------------------Lining material--------_-------- "-_______________- <br /> ❑ Size: Diameter------ -------------------------------Depth------------------=---------------------------- ----Liquid Capacity----------------------------gals. <br /> Privy:( Distance from nearest well____________ __-------------------------------------Distance from nearest building___________,_,__________________-_-______ <br /> ❑ Distance to nearest lot line____-____�`____-_ -�_ - <br /> -------------- -------------•---------•------=----------- ----------------------------------- <br /> Remodeling and/or repairing (describe):--------------- _ __ } t <br /> --=-----------=-------=--•-----------•--------------------- -------- <br /> -_-- � -----•----------••--••------------------ <br /> r « <br /> A ■ <br /> ----------------------------------- ---------------------------------7----------------------­------------------------------------Z------------------------------------------------------------------------------------------ <br /> I' <br /> --------------'•-----.""----`---------------------•----------------*•--•----------•---•-•-'---'•"--•--"-------------------------c--------•-------•----------------"------"------------------------------------------------ <br /> I'hereby certify that I have prepared +his applica+ion and that the work will'be-done'in accordance with San Joaquin County <br /> ordinanceJSI�Iaje laws, and rules an regulat'o of f an Joaquin Local Health District. <br /> (Signed)... - - ---- ------ - ----- --- --- -- - -- --- ---------- ---------------------ti-------------------------------------------- -----(Owner and/or Contractor) <br /> By -- -----`------------------------------------------------------(Title)----------------------..:--•-------- ------ <br /> (Plot plan, showing size of lot, location of systein in relation to wells,•buildings,etc.;can'be placed on reverse side). <br /> APPLI` r FOR DEPARTMENT USE ONLY <br /> CATION ACCEPIED•BY--" -------------- DATE-------- <br /> ' � ' <br /> ------- - ----------------- DATE <br /> REVIEWED BY-------------i------------------ ------------------------------------------ ------------- - - <br /> ------------------------------ <br /> BUILDING PERMIT ISSUED-----------------------------------------------------------------------------=-----------------------• DATE------------------------------------------------------------- <br /> Altera+ions and/or.recommendations:--------------------------------'---------- -------- .................---•------- --------------------------------------------------- ------- <br /> --- -- ---- -- •- ------• - ---•---••----------------------------------•-•--•--------•-•-•--.... <br /> ---- --------------- - ------:----` '----" ----------------------------•----------------------------------••------------------------------ ------------------- ------------------------------------•-•-- <br /> t 4 � <br /> ---------- <br /> FINAL—ENSPECTION BY:----------- - <br /> - / <br /> ----- Date------------ ----•-- = -------------------------------- <br /> SAN <br /> ------- -------------....._...SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2 Revised W-2100 <br />