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Z____ <br /> APPLICATION FOP, SANITATION PERMIT Permit No— ----------- <br /> (Complete in Duplicate) Date Issued <br /> gA <br /> plica-�ion is hereby made to the San Joaquin Local Health Diqo7ct for a permit to construct and install the work herein described. <br /> This <br /> application is made in compliance with County Ordinance 549. <br /> JOB ADDRESS AND CATI <br /> ----- -- - -- -- -------- ---- ----------- ------- ---- --------------------------------Owner's NamepW . <br /> AddresS-- -- ----------------------------------------- <br /> ---- - -- _e------------------- ------- ------------------------------------------------------------------------------------------------------------ <br /> Contractor's Name- ------------ -- -------- -------------=------------- ---------------- Phone ; <br /> Installation <br /> ------------Z---------------------------------------------- <br /> Installation will serve: Residencex Apartment ouse E] Commercial E] Trailer Court E] Motel ❑ Other ❑ <br /> G7, <br /> Number of living units: --- Number of bedrooms Number of baths /.... Lot size _�---e'�9_X_ ___________________ <br /> Water Supply: Public system Community system [-] Private ❑ Depth to Water TabI.09/_1__9f+. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay L] Aclob� Hardpan E] <br /> Previous Application Made: Yes E] No New Construction: Yes E] <br /> No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic T k: Distance from nearest well-----------------Distance from fLnclafion--------------------Material------------------------------------------------ <br /> • No. of compartments--------------------------Size--------------------------------Liquid depth------------------------- Capacity---------------------_ <br /> j is posaI iel Distance from nearest well_________-_-_-_---------D;stance from foundation------------------- Dist(�nce to nearest lot line_______________ <br /> • Number <br /> ine----------------- <br /> Number of lines---------;------------ -----------Length of each line------------------------------Width of trench----------------------------------- <br /> Typ <br /> fench.---------------------------------- <br /> Typ.e of filter material----- --------------------Depth of filter material____.___-iTotal length--'---------------------------------------- <br /> Seep Pi Distance to nearest well_ ___Distance fr"mjoun Distance to nearest lot line__ -- _e---- <br /> ize: D' .0Z <br /> material_ Diameter____ ---------------De h_;;j? <br /> Number of pits-------/------------U,;ng f I e- - ------ -S - - - ----------------- <br /> Cessp6oh Distance from nearest well______-_________Distance from foundation------------------- Lining .material___-_____________-_-_____________-. <br /> ❑; <br /> maferi6l-------------------------------------- <br /> F-1; Size: Diameter------------------ ------------------Depih----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-- ------- --------------------------------------Distance from nearest building____---__-.-----------_______________--__. <br /> ❑ Distance <br /> uilding------------ ---------------------------- <br /> Distanceto nearest lot line------------- ...K--------------------------------- ----------------- -------I--------------- ------------------ <br /> Rem deling an or repairing (desc ----- ------------- - -- -------- <br /> V-------------------- ------------------------ ------------ ----------------------------------------------------­­---------------------- <br /> ------------------ <br /> -------------- ----------- -------------- -------------------------------------------------------------------- ---------------------------------------------I------------------------------------------------------ <br /> --------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- <br /> I hereby certify have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,/KR6�laws, d r es and lerg5ugaons of the San Joaquin Local Health District. <br /> (Signed)------ ---- -- ------------------------------------------ -- ---------- wner and/or Contractor) <br /> ---------------------------------- <br /> By:-------------------------------------- ---------------------------------------------------------------------(T itle -- ------ <br /> Rem deli, n or a (d,,c <br /> .... .... -------------- <br /> ......... . ..... ................ ...... ------------ <br /> �.r.�y certif .�,a, la,. <br /> (Plot plan, showing size'of lot, cation o system in relation to wells, buildings, etc., can be pi on reverse e. <br /> _e�_ ,; <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ----------------------- ------- ------- 4N------------------------------ <br /> DATE------------- ------------ <br /> REVIEWED BY------------------------------------------------------------------------------------ - ------------ ------------------ DATE-- ---------: ... <br /> ............. <br /> BUILDING PERMIT ISSUED___________________-__ <br /> -------------------------------------•--------------------------------------. DATE------------------------------ -- -------------------------- <br /> Alterations <br /> --------------- <br /> Alterati ns andmxecomrnendations:----------#--------- J_ ---------------------------------------- --------- 'A'�----_------- <br /> 'ons -------A------------------------------- <br /> -------- --- - ------�_11444 ---- ------ <br /> .4-2- ---------- -- <br /> ----------------1_---------•------------ <br /> ---------- -- - <br /> ---------------------- -----------------/..............P------------------------------------------ ----------------------------------------------------------------------------------------------------------- <br /> ------- ----------------------------------------------------------------- ---- --- ------ ------------------ -------------------------------------- ---------------------------------------------------------------------- <br /> FINAL INSPECTION BY:--- -------------------------------------------- ----------- Date-------------------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American S4aef 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-4-2M Revised W-2100 <br />