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7 -5-V 6 -7, <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> Application <br /> is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> 's application is made in compliance with County Ordinance No. 49 e1v <br /> JOB ADDRESS AND TION-------- ------- ---- -- --------- --- <br /> ------------- ---- --- ----------- --- ------------------ ------ - ----------- -------V------ --- <br /> Owner's Name-------------- --- ---- ---------- --------- -- ------- - . .---- -- ------- ---- -------------------------- Phone-- <br /> Address---------------------------- ----------- - - ------- -------- ---- ----------- ------- ----­----------- ------------------------ ---------------------- <br /> Contractor's Name-------------------------------------------- ------------------- Phone. <br /> ----------- <br /> Installation will serve: Residence E]. Apartment H se ❑ CommercialTrailer Court E] Motel El Other El <br /> Number of living units: Number of bedrooms _:�n= Number o &t s Lot Size 3...17.jau/j----------------------------- <br /> Water Supply: Public system ❑ Community system [I Private Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam El Clay El Adobe 9 Hardpan F] <br /> Previous Application Made: Yes E] No New Construction: Yes E] No <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-----------------Distance from foundation--------------------Material------------------------------------------------- <br /> ❑ No. of compartments-- ------- ---------------Size-------------------------------Liquid depth-------------------------Capacity---------- <br /> ---------- - -% <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> F1 Number of lines-----------------------------------Length of each line-----------------.-----------.Width of trench-----------------------------------IN, <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seeps e Pit: Distance to nearest well_#6401--------Distance from fowndafion---6.............Distance to nearest lot line__115;Z�l------ <br /> ning Size: Diameter--- -------- <br /> Number of p;fs.07 Li Dept�--- --------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material----------------- ------------------- <br /> F1 Size: Diameter--------------------------------------Dept h----------------------- ----------------------------Liquid Capacity_-------------------------gals. <br /> Privy. Distance from nearest well------------------------- -----------------------Distance from nearest building------..-_.-_.------_----___-._ <br /> ❑ <br /> uiUing----- -------------------------El Distance to nearest lot line------- ---------------------- ----------------------------- -- ---- -----I------ ----- --------------- -- --- --------------- <br /> 0 <br /> Remodeling and/or re airing (c--e--s-c-r-i--b--------------------------------------------------------------------- <br /> -- ---- --------------------- ------- --- <br /> ------ - -- ------- <br /> -- <br /> -------------- ---- -- --- r------ <br /> J <br /> ------- --- -- - -----------& -- ----------- <br /> ------------------------------------------------------ ----------------------------------------------------------------------------------------------------------- - -------------------------------------------- - -- - <br /> I hereby certify that I ve r pared this appl' f' i and that the work will be clone In ac r ante with San Joaquin County <br /> 'ca 'y <br /> ordinances, State laws, an rule a d regulations of fl San Jciaiquja:�cal Health District. <br /> (Signed)-----------_---------- -- ------ -•---------------- -------- ........ ...... --------- -------------------------------------7­ _(Owner and/ Contcoctor) <br /> _(Owner <br /> By:-----------------_:::.. ..... . ... .... --- -- ---- - ------- - - - - - ---------------- -(Title)----- ---- <br /> (Plot plan, showing size location of system in re at on to wells, buildings, etc., can be plaon reverse side). <br /> FOR DEPAYME!9.-��ONLY <br /> APPLICATION ACCEPTED BY---- ---------------- --------- -- ----- V--------------------------------- DATE--------------" l <br /> REVIEWED <br /> ATE-------------- <br /> REVIEWEDBY-------------------------------------------------------------------- -------------------------------------- DATE----- ------ <br /> BUILDING PERMIT ISSUED---------------------------------------------- ------ - ------------------------------------ DATE--------- ------------------------------------ <br /> Alterations and/or recommendations--------------- -------------- <br /> ---------------------=------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> --------------------------------------------------------------•-- ------------ ----------------------------------------------------------------------------------------------------------------------------­--------------- <br /> ------------------------------­_­------- -------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------- ---------------------------------------------------------- -------------------- -----------­-­-- -------- ------------------------- ----------------------- <br /> FINAL INSPECTION BY:..__.-- -----9r-�_ .....�1 ---------- Date--------------- <br /> r----------------------------------------- <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 />