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Permit No. ------ <br /> APPLICATION FOR SANITATION PERMITN/ <br /> lComplete in Duplicate) Date issued ___ -�-- <br /> it to construct and install the work herein described. <br /> Applica{ion is hereby made to the San Joaquin Local Health District for a perm <br /> This application is made in compliance with County Ordinance'No. 549 <br /> --- -----------•--_---------- <br /> ---- <br /> JOB ADDRESS ANb LO ATION------- -�-- pone---------------- <br /> - .e .-------------•-- <br /> Owner s Name-- ----- _ ---------------------------------- <br /> ----------------­--- <br /> --------_ + Fh <br /> Address-------- -- ; ; •---------------------- ------- <br /> --•---- -------••----------- -• one <br /> r - - -------- ----- <br /> --- --------------- <br /> ---- <br /> Contractor's Name-----=----•---• Motel ❑ Other ❑ <br /> Installation will serve: ;Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> } <br /> g s --- --- Number of baths - Lot size ------�'�----�-�-- �-�--------------------- <br /> 2-- <br /> Number of living units: ___-___,a umber of bedroom <br /> ft- <br /> Water Supply: . Public system'❑'°Community system � Private ❑ Depth to Water Table __.____. <br /> Character of soil to a'depth of 3 feet: Sand C] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay 11 Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ <br /> No (L 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.) <br /> Septic Tank: Distance from nearest wel -----------------Distance from foundation--------------------Materia______________-- <br /> i No:-of compartments---------------------------Size------••-- -----------'---------Liquid depth------- --- -- ---- - Capacity <br /> ❑s .. E <br /> pisposal Field: Distance f*om nearest well.______________Distance from foundation_-___.__.______----Distance to nearest lot line__..___.._______. <br /> Number of lines-----_•---------------------------Length of each line--------------------------- <br /> h <br /> Width of trench € , <br /> ❑ , Depth of filter material------- --`----Total length-------------------------------=�-f <br /> Type of filter material_______________ _t_ f <br /> t. <br /> See a"'Pit:""" " Distance to nearesty�well_.__=,-- ---Distance from foundation___________________Distance to nearest lot line___ ___ <br /> Number of pits------r! -___---- --.Linin material-------------- --'----.Size: Diameter__._-x {f--------Depth--------- '- ---•== <br /> Cesspool: Distance f�•om nearest well_-_:___ Distance from'foundation------.'f1___.__.Lining material_________ <br /> Size: Diameter y '- X- - -------Depth ----- Liquid Capacity gals. ' <br /> y Distance from nearest building----------------------------------------------- <br /> 1 Distance from nearest well------------------------ <br /> Privy:: = <br /> ❑ .—Distance to nearest; ot; ane----=----------- ----=--_--=------- <br /> -------------------- <br /> Remodeling and/or repairing (describe)---------------•-----------,------------------------------------------••r--�----- - ----------------- <br /> ? - ( ir4 - <br /> ----- 1. I . <br /> ------- ----•-----------------------=---•---•-------- ------------------------ ; <br /> s. .. ' <br /> ------- --•------------------------------------•---- n - cco ---------------------------------------- <br /> iwith <br /> u <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 /> ! - � caner and/or. Contractor <br /> d � - -------------- --------------- 10 <br /> o. <br /> (Signe <br /> - - ------ - ----- - <br /> ` - (Title) <br /> D ------------------------------------------------------------------------- -- ---•----1- . <br /> (Plot plan, showing size of lot, location of system in relation+o-wells, buildings, etc., can be placed on reverse side). <br /> f <br /> - F FOR DEPARTMENT USE ONLY <br /> J �`c DATE------------ 1 ------ <br /> APPLICATION ACCEPTED BY------------- --------------- --- f <br /> = = DATE.---------- <br /> -------------------------- <br /> REVIEWEDBY------- ----------------------------------- ------------ <br /> BUILDING PERMIT ISSUED------------------- -------------------------- '--------------------:-=--=------- - DATE <br /> l <br /> k rtl_ <br /> ' <br /> _..__.. -- - --------------------- <br /> 4(=; <br /> ------ <br /> Alterations and/or recommendations.-_' - -ti <br /> ------------------- --------------------_ ------------- <br /> ----- <br /> ------- - <br /> -- <br /> --------------------- <br /> f <br /> -------------- <br /> ------------------------- <br /> --------------- <br /> - <br /> ----------------------------------- <br /> Date------ ---- <br /> FINAL, INSPECTION BY:._----- --- -- >— /�- ! = _. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> 130 South American Street Manteca, California Tracy, California <br /> Stockton, California Lodi, California , <br /> iii ES-9-2M ; Revised W-2100 <br />