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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> Applica4-ion 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 ANDLOCATiQ --------------------- <br /> --------- <br /> ------- <br /> N___-_____ --------- ---- ------U_ <br /> *-1-------- <br /> Owner's Name- - --------- - -—-- -----------11 ------------------ <br /> Phone <br /> Addreus ----—----- --- -- <br /> Contractor's Name ------------------------- --------------------------------------------- Phone-,7--:,/ 4��e---- <br /> ------- ;......... ---------------- <br /> Installation will serve: Residence;& partmerif House [-] Commercial 0 Trailer Court E] Motel [] Other El <br /> Number of living units: /--- Number of bedrooms_Z__ Number of baths Lot size ---------------------- <br /> Wafe('Supply: Public system E] Community system [_1 Private Depth to Water Table/,�� ft. <br /> Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam Clay Loam Ej Clay E] Adobe[]" ' Hardpan F] <br /> Previous Application Made: Yes 0 No New Construction: Yes Ur No [:] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> eptic T k: Distance from nearest well---_--—--------Distance from foundation--------------------Material------------------------------------------------ <br /> No. o� compartments---------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal <br /> -----Capacity----------------------- <br /> -7well:.,? / Distance from foundation__,e��__�-:--_.Distance to nearest lot <br /> Disposall N d: Distance from nearest <br /> Number o{ lines___._____________________ __--Length of each line----------76,7------------Width of trench-,--.?--'-- <br /> r - 7----------------- <br /> Type OT filter materia�l�_ -----Depth of filter maferiar./f"_____._.Total length---------- -7 ------------------- <br /> Seepage Pit: Distance to nearest well---------------------Distance from .foundation____.____-__-...___ Distance to nearest lot line__._____-_____._ <br /> ❑ <br /> ine_-------------- <br /> 172Number of pits----------------------Lining material----------------------.Size: Diameter-------.---------------Depth-------------------------------.- <br /> Cesspool: <br /> epth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.______._-___-__________:_______. <br /> ❑` Size: <br /> aterial-------------------------------------- <br /> Size: Diameter-------------------------------- ----Depth--------------------------------------------- ------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-___________.____________.___.___.______- <br /> Distance to nearest lot line-------------------- ---------------------------------- --------le----------------- -------------------- <br /> -------------- <br /> :e. I - ----- ---------- <br /> Remodeling Baer-r airin describe - ---- --- ­ ­.1----------------------- <br /> 0 describe=-- ------------ -----------------------------------��7-----------/--------------------:-------- <br /> -------------- -------------•------ -------------------- ----- --------------- --- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- <br /> ---- - ----------------------------------------------------------------------------------------------------*---------------------------------------------------------------------------------------------------- <br /> I <br /> hereby <br /> certify that I have prepared this application and that the work will be done-in accordance with San Joaquin County <br /> Z-di,a'nces, S!0@4aws, a . r s and regulations of the San Joaquin Local Health District. <br /> (Signed)---------- --- ---- --- -------- ------------------- ----------------------------- ----------------- wrier and/or-Co tractor <br /> � i <br /> -------- ---- - ----f <br /> By: <br /> --- ------------------------------------------------ <br /> (T Zee <br /> --------------------- <br /> (Plot plan, showing sizdLof-lot, location of sysfern-in relation to wells, buildings, etc., can be plaEp-d on reverse sid J. <br /> FOR DEPARTMENT USE.ONLY <br /> APPLICATION ACCEPTED ----- -:---------------------------------------------------------------------------- DATE-—-------------------------------------------------- <br /> REVIEWED BY--------- -------- DATE---V,--------------------------------------------------- <br /> --------------------- - ------------------------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:----------------------------------------------------------------------------------------------------------------_------------------------------------------- <br /> ---------------------------------------------------­-------11--------­------------------- <br /> ---------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- --------------- <br /> -----------;----------------------------w---------------------------------------­--------------------------------------------------------------------­----------------__--,---__--______---_---__-._.________.____.._____.- <br /> FINAL <br /> - -------------------- ----------------------------- <br /> FINAL INSPECTION BY:.----- <br /> #"A ---- -- ------------------------------ Date--------- ------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f30 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manfeca, California Tracy, California— <br /> ES-9-2M Revised W-2100 <br />