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APPLICATION FOR SANITATION PERMIT Permit No. ..kzf. __ <br /> (Complete in Duplicate) <br /> pate issued -�---�:__.r�------ � <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 1 <br /> This application is made in compliance wit County Ordinance No. 549. <br /> Pei <br /> 0_k <br /> JOB ADDRESS AND L C TION-- ------------------------------•---------------r----------- ---- <br /> �J <br /> Owner's Na a----_C/, --_-i-_-_"�'v i <br /> - -------•-- ---------------------------------- ------------------------------------------ P - -- _------------ <br /> one- --- - -�• -- <br /> Address _........ ._. ..- ------------------- ----•-•---••----------------------------•- <br /> Contractor's Name----------------------------r '- ----------- -------------------- ---------------------------------•---------.-....----------------- Phone----------------------------------- <br /> Installation will serve: Residencie IXAp r ment House ❑ Commercial E] Trailer Court ❑ 1Motel L) Other ❑ <br /> Number of living units: _1-----Number of bedrooms .--- Number of baths .-_-1*--- Lot size ------r�---- --------------------------- <br /> Wafer Supply.'-Public system ❑ Community system ❑ Private & Depth.'fo'Watei:'Table <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 New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 1 <br /> (No septic tank or cesspool permitfed if public sewer is available within 200 feet.) t - - <br /> Septic Tank: Distance from nearest well" .-- Distance from fo tion------------ ---.M e-ia -------- ----------------------- <br /> ------------ - <br /> 1.No. of compartments°.-- $ize-- - - - - -- --Liquid depfh---- :--- --------Capacity-_-j � - <br /> Disposal Field: Distance from nearest well.___=7_(�____. Distance from foundatio _=`1�__�?-.-_----Distance to nearest lot�ine--_-C.-___---- ' <br /> Number of lines------ _--�-------------�j---Length of each line-----------0-- ------.Width of trench-.-- ___ <br /> JZ <br /> Tyif <br /> pe of filter material-",5'- __'�-n� -Depth of filter material-----J_-S_-----.---.Total length-__.-_-.1 --a---l-----::_`- <br /> Seepage Pit: Distance nearest well--------------�__---Distance from foundation.........--.....---.Distance to nearest lot).in <br /> ------ <br /> Seepage <br /> ), <br /> ❑ Number of pits material-----°-,-------------.Size: Diameter-----------------_.__--.Depth---------:�---;-------------- <br /> -- <br /> Cesspool: Distance from nearest well-------- ------Distance from foundation--------------------Lining material----_-,-:----_- -----1 ------. <br /> El <br /> T <br /> Size: Diameter------------------ -------------------Depth----------------- ---Li Liquid Capacity-. jf els. j <br /> Q <br /> Privy: Distance from. nearest,well-__._--___-__"_ -------------------_ ---.__,____;._Distance from nearest building----------------------_------------------- <br /> Distance <br /> ---.-.Distance to nearest lot line------------------------- - -- <br /> Remodeling and/or repairing describe:__ ,.- *-^................... <br /> -----------------------------------------------------------------------------------------------------------------------------`------------------=--------------------- --..-.--.-_.......--I--------------------------- <br /> -------------------- <br /> -------------------------------------- - -- <br /> ------------------------------------------------------------------------•-----------------------..-.. -------­----------••--------•-------=- ---------------------------------------------- <br /> I I hereby certify thaf I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Sta laws, and rules and regul 'ons of the San Joaquin Local Health District. <br /> (signed .......... -- ------ ----------------------------- ------------ ---------.-----:----------------- (Owner and/or Contractor) <br /> By:. <br /> Y: ---------------=----------=-------------------------------'----------------:-------------------------- ------------------------(Title)-------------------------------------------------- <br /> ----•--•---•------•---------------- -- -- ------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a <br /> r <br /> 4 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- - --�_a ----------- -- -- ----- --=•--••-------•----------- DATE------ -�:REVIEWED BY---------------------------------------- - -- ------ DATE . --•------------------- <br /> BUILDING PERMIT ISSUED--------------_----- <br /> ------------------------- ---------------------.._ DATE...... --t=- ---------------- <br /> ---------------------------- <br /> Alterations and/or recommendations-------------------------- ------------------------------_=_•_--------_------•------------------= <br /> -------•-------------------------------------------- ---- ' <br /> ----------------------------------- -------------------------------------`-------------------------------------------------------------------------------------------------------- ----._..---------------------- <br /> .--------------FINAL INSPECTION BY:.-4} --- <br /> ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i r 1 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> , r Stockton, California Lodi, California Manteca, California Tracy. California <br /> ES-9-2i4 Revised W-2100 <br />