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APPLICATION FOR SANITATION PERMIT Permit No. -------------------- <br /> (Complete in Duplicate) Date Issued <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 <br /> application is made in compliance with County Ordinance No 549 <br /> 11111 / ------ ► 2-1a I � - <br /> - ----------- <br /> JOB ADDRESS ANO oLOCATION-------- ---- -- <br /> ---- -------- <br /> Owner's Name----- <br /> Phonef4UL-14------ <br /> � <br /> • <br /> ---- ---- ----- ------- -------------- ------------------ ------------------------- n, -------------------------------------- <br /> Address-------IC5_19-- --- --- --- -,c- <br /> ------------------------------------------------­­------------------------------------------------------------------------- <br /> I <br /> Contractor's Narne-. --------- ------ - --- ---- --------------------------------------------------------------- ----------I--------=­------------------------ Phone----------------------------------- <br /> Installation will serve: Residence Apartment House E] Commercial E] Trailer Court [I Motel Ej oer <br /> Number of living units: umber of bedrooms ____/_ Number of baths ---L Lot size <br /> Water Supply: PublicsystemCommunity system E] Private F1 Depth to Wafer Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel E] Sandy loam <br /> .Clay Loam Ej Clay C] Adobe Le/Hardpan E] <br /> E] No New Construction: Yes No <br /> Previous Application Made: Yes Fj <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted ij u ic sower is available within 200 feet.) <br /> _p 611 <br /> ------------ <br /> Se ank: Distance from nearest wef_ .4Vd&1st W,qkfr 1111 f afionlo_��Mafejaj__ <br /> I �e�pfn _ apa.ily <br /> - ------- - -xe <br /> PVT No. of compartments_--____ <br /> -------Liquid 4epffi--- -----7-- ---------Capacity------ <br /> Disposal Field: Distance from nearest we Distance from foundation ------- - ----- istance to nearest 1pf �iioej i6------- <br /> Number oi'.Iines ------- ength of each line------------ i119 _,r__.Widfh of trench_--_0_________________________------I--------------------- <br /> C <br /> Type of filter rin . 'd lepth of filter material----------- --------Total length--------- <br /> Seepage'Pit: Distance to nearest well_____._!___----------Distance from foundation-------------------Distance to nearest lot❑ line-----­:---------- <br /> Number of pifs------ ---------------Lining material------------------------Size: Diameter--------------r---------Depfh�--------------------------------- <br /> Cesspool: Distance from nearest well__,__ -i--------- ------Distance from foundation__________-_- --- Lining material_____________________________________- <br /> F-1 Size:,Diamefer--------- ----------------7t <br /> -------Depth----------------------------------------------------Liquid Capa 1 y------------------------,-.gals, <br /> T <br /> Privy:' Distance from nearest well---------------------------------------------- --Mstance from nearest building-------------------------------------___-- <br /> --------------------------- <br /> ❑ <br /> Distance to nearest lot 11ne------ -- --------------------------------------------------- <br /> Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- <br /> -------------------------------r------------------------------- . <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 /> (Sign .... .A�7�-----------------------------------------------------------------(Owner and/or Contractor) <br /> BY--------_--------- <br /> ............ --- <br /> --------------------------------------------------- <br /> ---------------------------------(Title)---------------- ------------------------ -- ---------------- <br /> (Plot plan, showing tine of lot, location' of system in relation to wells,' buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY i <br /> APPLICATION ACCEPTED 0- ------------ <br /> ... ------- ---- -- ------------------------------------------------------------ DATE-;: ---- <br /> ,--- ---------•- <br /> REVIEWED BY-------------------------------- <br /> - ------'------------------------------------=-----------• -------------------- DATE----_ ------- <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------- ---------------------------------- DATE---------- ------------------- <br /> Alterations and/or recommendations:-- ----------------------------------------------- ------------------------------------------------- <br /> ------------------------------------------------------------------------------ IL --7 1- ------ ---------------------- -----------------f------------- ------ ------------ <br /> ----------I--------------------------------------------------------- ------ <br /> - ------------- <br /> --------------------------------- - _4,eje --- -------/ <br /> ----------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------­­­­-------------------------___------------------------- --------------------------------- ----- <br /> ----- ---------------------------------------------------------------------- <br /> FINAL INSPECTION BY_____________________ <br /> :____ ------------I------ --------------------- 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 ; I Revised W-2100 <br />