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i <br /> V5^"' APPLICATION FOR SANITATION PERMIT Perm No. ----d'---__ <br /> q <br /> ro° P�r}SyT 9 (Complete in Duplicate) <br /> 3' r' 7� �t,► . Date Issued <br /> O�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 O dinance No. 49. <br /> JOBADDRESS rD.......CATION�--Z-4-z- 3 -- ---- ------------------------- ------------------------------------------------------------------------------------ <br /> - Phone " ,f <br /> Address. 4----••--- -------- -- -- -------- ---• -!C-` L_x i._----.--------------------------------------------------------------------------------------------------------- <br /> Contractor's Name--- -•-------------- ----•---------------------------------------------------------------------------------- Phone----------------------------------- <br /> --- <br /> will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ <br /> Number of living units: ______ Number of bedrooms -------- Number of baths -------- Lot size ____________________---_-------____-___--_----_-___--_----_ <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Ciayloam ❑ Clay ❑ Adobe❑ Hardpan ❑ Q �Y <br /># Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: -' • <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.)SeRtt <br /> is Talk: Distance from nearest well-----------------Distance from foundation____' a".__.Material __•__-_----_-_______. <br /> No. of compartments-------------,-- -----__Size--------------------------------Liquid,de�th--------------------------Capacity-------------------A-- <br /> Di�pos Fiel Distance from nearest woll. v--.Distance from foundation____ ____�}./_.Distance to nearest to lin / <br /> Dumber of lines__________ 1 _ _ _Length of each line-_---_-:_-.-____ 1 Width of trench___ _ ,�_�.__----.-----__ <br /> - <br /> Type of filter maferiaL__._, j'�pepth of filter material----- ___..__Total length--------- --- ---___--_-___.____-__-- <br /> M Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_.--•_----__----_ <br /> ❑ Number of pits--------------------_Lining material-----------------------Size: Diameter--------•--,-----------Depth--------------------------------- <br /> Cesspool: Distance from,nearest well_________________Distance from foundation--------------------Lining material-------------------------------------- <br /> Size: <br /> ------____-____- ..__---------_____-. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-----__--.____-____--___-_------_________-Distance from nearest building----____-______________________________ <br /> f ❑ Distance to nearest lot line <br /> Remod ing and/or, repairing (describe):--------------v------- x.--�-------•- <br /> ------------ ------ <br /> - =--------------•------------••------------------------------- -------------- <br /> -----------------­-- <br /> ...................................... --•-•-------------------------------- <br /> ••------------------------------------ <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br />` ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)-•--- --- ----f------------------------------------ ----------------------------(Owner and/or,Contractor) <br /> By:------------------------------ t---------------------------------------------------------------------------------------(Title)------------------------------------ ----------------------------------------------------•--------(Title)------------------------------------ --------------------------- ' s <br /> (Plot plan, showing size of lot, loca+ion of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY____(_-- ----- --- ----------------------------------•--------------------------------------- DATI=_ ------------------ <br /> REVIEWEDBY----------------------------------------- ---------------------------------------------- -------------------------- DATE-------� '" <br /> BUILDINGPERMIT ISSUED-------•---------------------------------------------------------------------------------------------- DATE------------------ <br /> _ <br /> Alterations and/or recommendations--------------------------- ----------------------------------------------------------------------------------------------------------•-------- <br /> 5 <br />{ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•___----__-_._-_- <br /> -----------------------------------------�-- <br /> -------1-_----.-..-_-_s-_-_-_---_-_-_- <br /> --------------------------------------- <br /> ----- <br /> F€NAL INSPECTION BY------------- ------- Date.-------- _______________________________________ <br /> SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California € <br /> ES-9-2M 8-51 Revised W-2100 <br />,, <br />