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APPLICATION FOR SANITATION PERMIT Permit No, <br /> (Complete in Duplicate) /� $' <br /> Date Issued ._-./__. __��____.. <br /> Applica+ion 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 rC'ounty Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION----'�-7-T/f------------ , t"., R.- ---- -•--------•-------------•--•--•------------------------------------.- <br /> Owner's Name .....--- -` '� --�f"�-•------•-- - ------------------------------------------ Phone_--------•--•---•--•-•-•---•-------- <br /> Address.......___---------------------------------- r f } ! --------------- ------- <br /> Contractor's Name................._------..--------------------------- - - ------------ ------ Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ <br /> Number of living units: _2_ Number of bedrooms --6-_ Number of baths 3___- Lot size ------- .--._20_____________________ <br /> Water Supply: Public system ❑ Community system ❑ Private,W 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 ❑ Nojjg �New Construction: Yes " No ❑ `AWStS f}' ve,.d /h <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____S�__.Distance from <br /> t <br /> founda-tion-_ ZD--------Materia _____ <br /> No. of compartments-______Z----_- --Size �_!_� Uquid deth ___ ____ <br /> p __Capacity <br /> ____________---_G <br /> Dis <br /> I Field: Distance from nearest well ._-____Distance from foundation to nearest lot line------J- <br /> Number of lines----------L4------_-__- Length of each lin e--------_Ad0 Width of french._________�-�`_/______________ <br /> Type of filter material_��.�v�. __u1___ _4th of filter material___--__—/P---------Total length________________�0-----_-------- <br /> Seepage Pit: Distance to nearest well-__________.________Distance from foundation--------------------Distance to nearest lot line___.__________ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter_-----------------------Depth--------------.-----------_------ v <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------------------------------------- <br /> ElSize: Diameter------------- ------------- - --------Depth------------------------------------------ ---------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well---------------------------------------.---------Distance from nearest building________________-_-__________._ <br /> ---------ID - <br /> Distance to nearest lot line - - - - --------- -- ----- --•--•--••-----...._.._-.------------------------------------- <br /> Remodeling and/or repairing (describe)---- ----- ------------------•-----------------------------------------------.-•----------------•-------•--••-----------•---•--------------------------- <br /> ..............I.......----------•-----------------------------------------------------------------------------------------------------------------------•------------------------------------•------------------------------ <br /> ------------------•------------••------------------------------------•--------------------------------•------------------------•-•--------•----------------------•------------------------------------------------------------ <br /> -------------------------------------------I----------- ..... --------------------••------------------------------------------------------------------------------------------------------------------------------- <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, Stat laws, and rules d regulations of the San Joaquin Local Health District. <br /> F \ <br /> (Signed) �-j <br /> _2 (Owner and/or Contractors U <br /> By:------------------------------------- ---------------------------------- ---------------------------------------------------------(Title)---------------------------------- ---- <br /> - ----------------------- <br /> (Plot plan, showing size of lot, cation of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----_--------___ DATE______________ <br /> REVIEWEDBY--------------------------------------------- --- ---------- - -- ---------------------------------- DATE------------------� � -------•-------- <br /> BUILDING PERMIT ISSUED---------------------- ------------------------------------------- ---------------------------------- DATE------ <br /> Alterations and/or recomm dations:-- -t_..... - - <br /> ,, __ <br /> --- -------- <br /> - ----------------------•-•-------- <br /> --------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------• <br /> FINAL INSPECTION BY:--- <br /> ------ ---_-_-- bate._--- '} <br /> ----------------- �f_--- = <br /> ------------------------------ <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 Codi, California Manteca, California Tracy, California <br /> ES-9---2M Revised W-2100 <br />