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APPLICATION FOR SANITATION PERMIT Permit No. 4--- - ---- <br /> (Complete in Duplicate) Date Issue <br /> Application is hereby made to the San Joaquin Local Health District for 6 permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> .7D <br /> — - ---------- -- ------ --------------------------------------- <br /> JOB ADDRESS AND LOC TION---------- V7C�'� ...... <br /> ------ ............. ------------- ----- <br /> Owne <br /> ';Z, e <br /> r's Nam —-------------------- <br /> r's Nam ---- 2,Ze. or <br /> ,ssAddress ... . .......... ---------------------------------- <br /> -------- ----------------- -------------_-- Phone--- <br /> ----------------------------------------------- <br /> Contractor's Name.----------- .. .... ---- -------- <br /> Installation will serve: Residence "Apartment House E] Commercial E] Trailer Court E] Motel E] Other E] <br /> Number of living units: of bedrooms j--- Number of bath, __/--- Lot size <br /> ------------------------- <br /> Water Supply: Public system E]Community system Private D Depth to Water Table F�ff. <br /> Character of soil.to a depth �f3 feet:,sand ❑ Gravel [] Sandy Loam E] Clay Loam E] Clay ❑ Adobe ]`Hardpan ❑ <br /> PrevioaAp-plication Made: Yesb' No f New Construction: Yes NE] <br /> Flo <br /> TYPE OF INS:TALLATION AND SPECIFI <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.] <br /> Se tic Tank Distance from nearest.v4l-----------------Distance from foundation--------_--------Material-------- ------ --------------------------------- <br /> No. of compartments--------------------- ----Size---------------- - --- ---Liquid depth--- -n=------- ......Capacity----- ----------------- <br /> o � <br /> sposal <br /> apacity------------------------ <br /> sposal Fi Id.. DisfancefrjorA nearest well-----.-.--------Distance from founclafion_�_ -----Distance to nearest lot line----------------- <br /> i. N.Umor��oi lines::-----------------------------------Length of each line----------------- ------------Width of trench------.----------------------- <br /> T <br /> yp`e of.filter material.........:...............Depth of filter material-------- --------------Total length___.-.-..................-.-.--..........- �/ <br /> See a <br /> ength------------------------------------------ <br /> Seepa e Pit. , Distance to nearest -----Distance fpm foundation__ - ------Distance to nearest lot line-....Y--------- <br /> Number of pits----- ---------------Lining m cIf ....Size; Diarriefer.......7..............Deplk------ ------------- <br /> Cesspool: Distance from;neare'sf well.................Distance from foundation--------------------Lining material_---------------------------------- <br /> F❑ Size: Diarneferi--------------------------------------Dept h------------------------ ----------------- ----Liquid Capacity----------------------------gals. <br /> Privy:, Distance from nearest well---------- ------------------------ -------------Distance from nearest building-.--.______-----.-.._...._...-______.__._. <br /> Distance to nearest lot line----------------------------------------- - -----------------------I-------------- <br /> Remodeling and/or repairin 2� ----- ---------- <br /> (describe):------z.-I--- ----- -- --- ------- <br /> ----------------- --------------------------------------- --------------------------------------------------------------- <br /> --------------------------------- ----------------------------------------------7------ 4 <br /> -----------------------.......................-----------------------------------------------..­.­---------------------------------- <br /> '1110 <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------I—---------------------------------------------------------------- <br /> A <br /> I'hereiry 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 regulations of the San Joaquin Local Health District. <br /> (Signed)---..------- � - -------- ---------------------------------------- "(Ow6r and/or Contractor] <br /> -------------------------------------------- ------r--------------------------------------- --- --- ---- --- <br /> By:........ ffitle - --------------- <br /> - '71. er <br /> t, location of system in relation to wells, buildings, etc., can be placed on reverse side)/ <br /> (Plot plan, showing size o lo;.-- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_-- -------- <br /> ------------------------------------------ --------------- ---------------- DATE'_------------------------------------------------------- <br /> REVIEWEDBY---------------------------------- ------------------------------ ------------------------------------------------ DATE----- <br /> BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-----------1 ----------------------------------------------- <br /> Alterationsand/or recommendations:---------------------------- ----------------------------------- ---------------------------------------------------------_---------------------------------I---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ..........I-----------------------------------------------------------------------------------------------------------------------------------------------.­­­.......... •--------.....-----------...--------------------- <br /> ------------------------ <br /> ..........­------------- ---------------------- <br /> ---­------------------:•----------------------­.............-------- -------------------------------------------------------------------------------------------------------------------------------------- <br /> - ------- ­--------------- ------------------------------------------- ----------------- ------------------ - <br /> FINAL ------------------------------------------------------- <br /> - <br /> %INSPECTION BY:------------ --------------- --- Date_-------------------- <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 10.52 Revised W-2100 <br />