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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in .Duplicate) Date Issued ---- <br /> Application <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. <br /> JOB ADDRESS AND LOCATIO 1 �� --------a0 -- A1A ----------------------------------- <br /> Owner's Name--------------- - �/� ------ <br /> Phone--------- <br /> Address---------------------------- ..................... ----------- ---------------------------- --------- <br /> ----------------------------------- <br /> Gontractor's Name--------_---------- ---------------------------- Phone-------------- ------------- <br /> - <br /> -�]-----• p----------- ---------- [-] <br /> - - ❑ -- ❑ ❑ ❑ <br /> Installation will serve: Residence Apartment House Commercial Trailer Court Motel Other - <br /> Number of living units. _�___ Number of bedrooms ___::P,Number of baths _ ____ Lot size ------------------------ <br /> Wafer <br /> ----_Water Supply: Public system ❑ Community system ❑ Private n Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel 0 Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑� <br /> Previous Application Made: Yes ❑ No ® New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: CN <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> $ ........ _�:___-__�______ <br /> ® No. of compartments------�•---------- --Size___-��- -- -� .�Psquid depth---------¢_-2- ------Capacity_.....7ed..... <br /> Disposal Field: Distance from nearest well ___60_.___.Distance from foundation_____-ZG________Distance to nearest lot line____ _______ <br /> ® Number of lines______________ _ _-�-- _ Length of each line-------�y_Q-r__4---------Width of trench______�_S_�;______________ <br /> Type of filter material_ cP------ --__Depth of filter materiaI__.a1K__________-Total length-------L4c ?----•_________________ <br /> 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: Diameter-------------------------------------Depth--------------------------------------- -------------Liquid Capacity----------------------------gals, <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- <br /> ElDistance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> t <br /> Remcdeiing and/or repairing (describe):-------------------------------------------------------------------------------------'------------- ---- " <br /> 4 i <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 /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------C - _ -l�'l ---------------------------------------- --------------------------------------------(Owner and/or Contractor) <br /> --------------------- <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-------- _ y ----------- DATE--------- ' <br /> REVIEWEDBY------------------------------------------------- -------------------- - ----------------------------------------------- DATE-- •------------------ -- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------------------------------- <br /> Alterations and/or recommendations----------- -------------------------� '------ ------------- ' ••----�---••------------- <br /> ,- ------- -_•------------------------------------- <br /> ----------------------- ------------­--------------- ---------------------------------- ---------------------- ► * --------------------------------------------------------- --------------.-- <br /> -- --------------------------------------------------------- f <br /> - ------- -- -� ---------- <br /> ---------------------- -------------- _ j `, ------------------------'----- --------------- - --___ - _ _ _ <br /> FINAL INSPECTION BY:------ Ic`--- r --- Date------------------------------------------------------------------------------- <br /> S. JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South America-4it 300 West Oak Street 132 Sycamore Street 8!4 North "C" Street <br /> 11 <br /> Stockton, California P� Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 9-51 Revised W-2100 <br />