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APPLICATION FOR SANITATION PERMIT Permit No. .. <br /> Duplicate)(Complete in Du li <br /> p } Date Issued/ <br /> ��_-�" � <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 County Orclipaqce No. 549. <br /> 14V- <br /> JOB ADDRESS AND LOCATI N-- --------- -------------- - --='`-�� <br /> Owner's Name.__"''''-' ­- - ----- ----------------------------------------- --------------------------------------------- Phone---- ------------------------------- <br /> �. t'- _. ------------------------------------------ <br /> Address- -------------------------------.-.... _. -- --- ------------ ,�- <br /> Contractor's Name - l� ---------------------- -------------- Phone------------•---------------------- <br /> Installation will serve: Resi enc}e [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel'E] Other ❑ <br /> Number of living units. _______ Number of bedrooms ___wNumber of baths ---I.... Lot size ___: ..c __.____.____ <br /> r.j <br /> ti Water Supply: Public system ❑ Community system ❑ Private ---* DepthVK <br /> to Water Table �ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 4 New Construction: Yes Z' No p ' r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: f <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �f <br /> � <br /> Se tic Tank: Distance from nearest well_--�"�__.�----Distan a from foundation__._-►----Material_-__ _E�"Z`y��t-: 1 j <br /> No. of compartments_.___-__�-- `�Liquid- p '-Capacity <br /> - ---------Size---- ----x-�-�-�---- ,,==d}}e��th-------- �--------- ----���-U�------- <br /> Disposal Field: Distance from nearest well----4-.(3.-----Distance from foundation __.`i7---__._.Distance to nearestlot line----/ ____ ' <br /> Number of lines_________, /_____________ Length of each line--------- _ -__. _�i__.Width of trench----- _ 0 _ r <br /> ---- - --------- <br /> Type of filter material, )---_Depth of filter material----.__._l'._--_______Total length -_�____ __ _ <br /> -- <br /> Seepage Pit: Distance to nearest.well----------------------Distance from foundation____________.._____.Distance to nearest lot Ime-----4 1_---_ <br /> ❑ Number of pits----------------------Lining material------------------------Size: Diameter-----------------------Depth_._.?-?- ----4"% <br /> Cesspool: Distance from. nearest well----------------- from foundation.................-._.Lining material_______ 0__ __. .._..__.__. <br /> ElSize: Diameter-- ----------------------------------Depth----------------------------------------------------Uqui.d_CapacitY._. _ -gals. <br /> Privy: Distance from nearest v✓ell----------------_--------------------------------Distance from nearest building.____.___.__._______________.______._._. <br /> ❑ Distance to nearest lot <br /> i � line------- -------------- -------- <br /> -----------------•--------------- <br /> ---,----------- ----------------- --------------------;-;-------�-----�---�c--;.--�-- <br /> -�- <br /> Re - ------ <br /> - - <br /> ------ ----- -� / <br /> - � �1 `7 �-� )-r•� =�- ___�'-�- --- ---- --- •---•------ ------ <br /> -------- <br /> � : <br /> --------------•-----------•------------- ---------- <br /> ----------- <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 /> F ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ..�1&a ---------.. �` � --- -----------------------------------------------------------------------(Owner and/or Contractor) <br /> BY: - ---------------------------•---------------------------------------------------------------(Title)- r <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> ► — �`"` FOR DEPARTMENT USE ONLY } <br /> APPLICATIONACCEPTED BY----- --------------------------- ---------- --- ----- -------------------------------------- DATE-------------------- i ------------------ <br /> REVIEWEDBY---------------------------------------------- -------------- - -------------------------------------- DATE-- -_� -------------------------------------- <br /> BUILDING PERMIT ISSUED------------------------------------ - --- ------ DATE------ ------------------ ------ <br /> Alterations ad or recommendations.--. - / •, _ ._ <br /> -- -- ------------------------------------- <br /> ----------- <br /> -- . _. ---------- <br /> ------------- <br /> ------ - ----------------------------------------------------7.------------- <br /> - ---------------------- ------------------------------- ------------------------------------------------------------------------- <br /> -------------------------------------------- -----------------------c -------------------- <br /> - -----------------------------------------------------------------Dafie-------- -_-------------)_ <br /> FINAL INSPECTION BY----- ---------------- ------�.-----. _-- <br /> U <br /> } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Sfreef 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M io-52 Revised W-2100 <br />