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APPLICATION FOR SANITATION PERMIT <br /> Permit No. .. . __ .-_g <br /> (Complete in Duplicate) Date Issued <br /> l <br /> Application 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 Cho/unty Ordinance No. 5`49. o <br /> JOB ADDRESS AND LOCATION----- _d._/J': _ -----'-------- <br /> C7. - -��-- --------- - - --7----- IO------/-C -L-- <br /> Owner's Name------------- -`r /✓ A/� i` - --------------------- Phone__ _f_ _0----------- <br /> Address------•------------- 9---------C_�#A-=aw ------ ----------------------- -•----------------------------------------------••---------------------------- <br /> - �f Phone. ��' <br /> Contractor's Name------.�<---��.__.. I - �� �` � 5 }- } <br /> Installation will serve: Residence U IApar rrient House [I Commercial E] Trailer Court [j Motel E] Other ❑ <br /> t ; # i <br /> Number of living units: J---- Number of bedrooms __ -_ Number of baths I___ Lot size --'�Gg____ �--------------------------- <br /> Water Supply: Public system ® Com munity�system b❑ Private:❑ Depth to Water Table ._-aft. <br /> Character of soil to a depth of 3 feet: Sand ❑"Gravel ❑ 'Sandy Loam ❑ 6,ay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ + <br /> Previous Application Made: Yes ❑ No U New Construction: Yes ® No ❑ r <br /> TYPE OF INSTALLATION AN D`SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public se er is available within 200 feet) - Materia------------------------------------------------- <br /> No. <br /> __ __ -- ____________. <br /> .menu--- -°---- '_4-�-`3-6----'( 3--Liquid depth-------&-Y-------- Capacity-S.C?�__�"=�_ <br /> ..�. .y i, <br /> Septic Tank: Distance from nearesr well -Distance from foundation__ <br /> 1 [y� No. of compartments______�i Size <br /> Distance from nearest well_/4001415=Distance from foundation___Zp-------_-_:Distance to nearest lot line------------ <br /> Disposal Field: ----- <br /> ® Number of lines----'---- ----------------------Length of each line'-_- .-«---'----- Width,of trench----- _-------.--------.---- `n <br /> Type of filter material__/i_�fi4°�4t:Depth of filter material--f�______f____Total length_:_.-_f�______________pp___�________ �7�, <br /> Seepage Pit: Distance to nearest welL/y,D ----- Distance from foundation____ _;.___.Distarc�e to nearest lot line_C7_ ----.-_- <br /> IDepth- <br /> ------ <br /> [ f Number of pitsI_____----Lining material__� _Q ! Size: Diameter__ _% __.-._______ __ a . <br /> Cesspool: Distance from nearest well'Y_------------__Distance from foundation----- -------------.Lining material_..----___-_______.__________-______ <br /> ❑ Size: Diameter------- ------------------------------Depth------ '-_-`--"- ------ `" ~""_------Liquid Capacity-L-----------------------..gals. <br /> Privy., Distance from nearest well-------------------------------------------------Distance from nearest building_,---------------------------------------- <br /> Distance <br /> ----------.------------------.-----.-.Distance to nearest lot line.'-'----------------------- --------------------------------------------- -------------------------------------------------------------------- <br /> 1 � a <br /> Remodelingand/oar repairing {describe}----------------- �---------------'--------------•-------------•------------------------------------------------------•-------------------------------- , <br /> -- _------•------------------------------- ----------------•--------------•-----------------------•---•-------------------,----• ----------------------------------------- <br /> ----------------------------- <br /> 3 ' <br /> 3 <br /> _____________________________________________________________________________�_c-__.__.____________-_________________._____________________________-______________________-______ ---------------------------------- -_ <br /> 1 hereby certify that I have prepared this`application and +hat the work will be done in'accordance with San Joaquin County <br /> ordinances, Siooaws, d It s d regulations of the San Joaquin Local Health District. , <br /> d � ' `---�` -'c-'-c------ �----------------- 7--.(Owner a d/or Contractor) <br /> (Signe ) <br /> BY:-----5-�' - ----- -•------------ ----- ----------------...- (Title)--I---- <br /> ((PlotIan showing size of lot, location of system in relation to wells, buildings, etc., can be placed o reverse side). <br /> plan, g <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY--------------------------- ----------------- ------------------------- DATE-----------/ ..f.{ ---------------------- <br /> REVIEWEDBY----------------------------------------------------------- ---------------•- -------------------------------------- DATE <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------- --------------------------------------- DATE. <br /> Alterationsand/or recommendations:---------------------------------------------------------------------------------------------•--------------------------------------------------------------- <br /> ----------------------------------1­---------------------------- -------------------••------------------ <br /> ----•-------------------------------------------------------------- ----------------------------------------------------------------------------•-------------------••-----------•----•--------------------- <br /> -----•------• Date-4.5--k-3 <br /> FINAL INSPECTION BY:----- � ___------ <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 Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />