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r - APPLICATION FOR SANITATION PERMIT Permi` <br /> (Complete in Duplicate) <br /> Date Issue <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 County Ordina o. 549. a <br /> JOB ADDRESS AND LOCATION______ ___ , k <br /> +fir. ------ <br /> Owner's Name----f-- `.. !d/.-a - ------------------------------- ------------------------------------ Phone------------------------------------ <br /> Address--- <br /> Contractor's Name---Q---- <br /> e <br /> ----------------------------------------------------------------------------------- <br /> - -- --- - •__-- _ __--_-- Phone7y-• `��_____•-_----• <br /> Installation will serve: *Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motte`l ❑ Other ❑ <br /> Number of living units: _/---- Number of bedrooms ___/__ Number of baths ___1__ Lot size- ('�tQ___X _ <br /> WC --- )----------------- <br /> I <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 K Hardpan ❑ \ <br /> Previous Application Made: Yes ❑ .No X New Construction: Yes ❑ No <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------------------Distance from foundation--------------------Material ____________________.______....___._.________. <br /> 6 1-6 No. of compartments-------------------------Size.-•--------------------------.--Liquid depth--------------------------Capacity----•------------ ---- <br /> Disposal Field: Distance from nearest well_________________Distant ro dation-------------------.Distance to nearest lot line.................. <br /> Number of lines-----------------------------------Len of eac. line------ ----------------------Width of french <br /> Type of filter material-------------------- ----b th of fii er I-- --------------------Total length----,---------------------------------- <br /> Seepage Pit: Distance to nearest well <br /> sta r m fo dati ...___Distance to nearest low)line_ _.4- --.-- <br /> NumberofT;ts---------_ Linin m era)____. iameter___. �_--r:-___.Depth... Q)~-- -1 <br /> Cesspool: Distance from nearest well-------------____'D tan m fo' ate n------------------- Lining material__.._-_-____-__________-____________. <br /> Size1 :. Diameter----:------------ <br /> iameter----:----------:-------------�'------_D'ep --- x-- - ----------------------- Liquid Capacity- ----------------- <br /> ---------gals. <br /> Privy: Distance <br /> sle _--___'-.::_--.---------------------- --•------ <br /> . <br /> , <br /> Distance from nearest building._______________________ <br /> ❑ e ----- <br /> Distancetoetlot In -------------- ---••--------------•--------------_-..------------------------- <br /> Remodeling and/or repairing (describe)------- --------------•---------•-•-----------------•----------•----------------•----------------------- <br /> ti <br /> -----------:--- ----------------------------------•--•--------------•----•-------•-------------k---------------------------------- <br /> --------=----------------•------------------------- •-------------- -------------------------------------•----------------------------•--------•-•-----•----------------•----------- <br /> ----------------------•-------------•-•-----------------------•----------------------------------------------------------------------------------- <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, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed). ---' - <br /> .............(Owner and/or Contractor <br /> 'By:------ -- - -- - - ----------------- ------------=--------------'--=-------•-----••--------------------- (Title) - 5 <br /> - <br /> (Plot plan, showing size'of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). <br /> -FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ 4------------ --------- <br /> -- - •----------------•---------- DATE------- `f <br /> REVIEWEDBY '--------- ------•-- �-- ----- - --------------------------------------------. DATE---------- <br /> BUILDING PERMIT ISSUED-------------------- <br /> ----------------- I-----------------------• ----l--------------------------------------------------- DATE------------ <br /> - --------------------- <br /> Alterations and/or-recommendations:- ,1------------------------------I------ ----- ------------------------------------------------------------- <br /> r <br /> I - r <br /> --------------------------••-------------------------------------------------------------------------------------------------------..... -----------------------------•-----------------=------------------------------- <br /> k ---� <br /> ______________________________________________________________________________ <br /> f <br /> -----------'---•--------------------'--------------------------- ------------------------------------ -------------------- -- -----------------------------------------•------------ <br /> 1 <br /> - <br /> FINAL INSPECTION BY:--'-------------- - ---1------------- Date------- -------� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 30D 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 />