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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in'Duplicate) Date Issued <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 Ordinance No. 549. -e�,J 2- <br /> C �4 <br /> JOB ADDRESS AND L I ION---- --- -- -- ------- ------ ---- -- )v -0----C:--- <br /> Owner's Name ----- ----- --------- I'd#----------------------------------- Phone------------------------------------ <br /> 111 <br /> Address------ -------- ---- ----- ----------- - - ---^------`------------------------- ......----------- <br /> Contractor's Name---------- Z------------------------------------------------------- ----------------------------------------------------- ftone----------------------------------- <br /> Installation will,serve: Residence Apartment House E] Commercial E] Trailer Court El Motel [I Other El <br /> Number of living units-'-I Number of bedrooms -Number of baths ---- -------------------------- <br /> Water Supply: Public system El Community system D PLrivaf,K Depth' to Wafer Table <br /> Chara'cter of soil to a depth of 3 feet: Sand C] Gravel D Sandy Loam [:] Clay Loam('El Clay E] Adobe E] Hardpan ❑ <br /> Previous Application Made: Yes L] No � New Construction: Yes No 0 <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____,5­0----Disfan;fr o ---------- <br /> No. of compartments---------- ----------Siz -4---Liquid depth---------0. ----------Capacity- <br /> 0;1�.. <br /> -A <br /> .t <br /> Disposal Field: Distance from nearest welll-D------Dista 0 nidrafio-cL---4�4_0__.Disfance to nearest lot lire <br /> Number of lines_____!)o-- . Length of each line--------7A0- ----------Width of trench------;Z/�----- ----------- <br /> --------- ------Total length_____________________ (. .._ <br /> Type of filter m C__Depth of filter material <br /> l_________________ <br /> ff � <br /> Seepage Pit: Distance to nearest lw'el---------------------Distance from foundation--------------------Distance fo nearest lot line_____._;--------- <br /> El Number of pits---------------------Lining,material-----------------------Size: Diameter---------- -- - --------Depth---------- ------------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----- ------—:-.-.Lining material--.--.--._ .--------____-_'--____.--. <br /> ❑�_ , n. Size: <br /> aterial---------- -------------------------- <br /> Size: Diameter- ------------Liguid .Capacity---------------------------1�_gals. <br /> Privy: Distance from nearest well-._:__ ------------ - --------------.--Distance from nearest building-_-__----____ _------------------------ <br /> n Distance to nearest lot line.-..------ _- - -------------------------- ------------- ------------- <br /> Remodeling... <br /> ...........d. cr rixng (rhe ): V------------------------------- <br /> -------- <br /> ------------------------------------------------------------------------ <br /> - <br /> ---------- <br /> ------ <br /> ---------- -------------------------------------- -----------------------------------------------j----------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------- <br /> -----------I.-----------------------------------------------------------------------------------w........----------------------------------•------------ <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.r6gulations of the San Joaquin Local Health District. <br /> .4 <br /> ---------------- ------------ <br /> --.---_(Owner and/or Contractor) <br /> (Signed)-.---------- ----------- —----- ------------------ <br /> By:-------------------------------------------------------------------------------------- ---------------------------------------------(Title)---------------------------:--------------------- --------------- <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 /> APPLICATION ACCEPTED BY-------------------------------- -- ---- ------:----------------------•----------- DATE---------------------- <br /> REVIEWED BY - <br /> � <br /> ----------- -------------------- ------- DATE=_ ------ ------------- <br /> - ----------------- <br /> -------------------------7---- <br /> BUILDINGPERMIT ISSUED--------------- ---- ------------ DA I E------------------------------------------------------------- <br /> Alterations and/or recommendaf ions: <br /> - ----------------------------------­­-------------------------:-------------------------------------_1_--------------_------------ <br /> ------------------------------------------------------------------------------- <br /> -------------------------------=------------------------ ------ --------------------------------------------- ------------------------ <br /> ------------ --------------------------- - - - ------- ----- ------------------------------------------------------------------------------------------------------------ ---------------------------------- <br /> �.; ------ ­------------- - ------------------------------------------------------------------------------------ --- - -------------------------------- <br /> -----------------k------ <br /> -----------------------------I----------------- ---------- --------- ---- ------------------------------------------------------ ----------------------------------------------- ----------------------------- <br /> FINAL INSPECTION ------ -------- Date_----------------------- --------- <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 Revised W-2100 <br />