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4'} APPLICATION FOR SANITATION PERMIT Permit No. - ............ <br /> (Complete in Duplicate)rt0h , <br /> Date Issued _____ _1 <br /> Appiicalion 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 /> c 0�o s�- • ----#---------lr� �9 �---- -- -----I ------� <br /> J013 ADDRESS AND LOCATION... D <br /> Owner's Name------`tel ---------------------- � � 1� --- ---- <br /> Address <br /> --- hLJ Phone <br /> �,/ p <br /> Address------- -------- ,, ---21 1------- ' 7�--"---�- - mm;-----C---- <br /> `P`"" ----------------------------------------------------•---------- <br /> 24 Contractor's Name------- --- -----------------------------------------------------•------- Phone- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial jff Trailer Court ❑ Motel ❑r Other ❑ <br /> Number of living units: J­ Number of bedrooms . Number of baths _v;F,7 Lot size ______�_�-----z/✓Le- ----------------- <br /> Water Supply: Public system ❑ Community system ❑ Private Y[ Depfli to Water Table 39_ ft. <br /> Character of soil to a depth of 3 feet: Sand Wr Gravel ❑ Sandy Loam [:]' Clay Loam ❑ Clay [] Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No Eff New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> ,; i ' <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f, <br /> Septic Tank: Distance from nearest well__J-P_______Distance from foundation__A __.___.__Material__.__'_____.__ __________-____. : <br /> 5d No. of compartments___3__---------------Size _ ------------k_K4.1".Liq,id Capacity__fA <br /> Disposal Field: Distance from nearest well---J. _ ___Distance from foundation---f0_---------Distance to nearest lot line__✓Qf_____� <br /> Number of lines------- :---_-----Length of each line-_ _ 5------------------Width of french----�y•_--------------_-•-- <br /> i <br /> Type of filter material_-?' 0;4k------Depth of filter material___._-, length_'_/tQ_`_______________________ <br /> Seepage Pit: Distance to nearest welL-16 ,� D D <br /> _ _____ Distance from foundation____.__..__..._..__Distance to nearest lot ..___.___. <br /> Number of pits_____ ____________Lining material S-__ %fit_ Size: Diameter____Y___�_ -_...___Depth------!0 --______---_--__-. <br /> Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material--------------------------------------i <br /> ❑ Size: Diameter--------------------------- -- -- ----Depth-------------------------------------------------­--'Liquid Capacity---------- ---------gals. <br /> Privy: Distance from nearest well.------------------------------------------------Distance from nearest building_-___-__-.___.______________-____..____._. <br /> ❑ Distance to nearest lot lire----------------------------- ------------------------------------------------------------------------------------------•--------------- <br /> Remodelingand/or repairing (describe)---------- -------------------------------------------------------------•---•--------•-------•--•----------------------------•----------------------- <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 regal ions of he San Joaquin Local Health District. <br /> 1 <br /> Si ned 1- {Owner and/or Contractor] <br /> ( g )----- j �, ) <br /> �Y: lam'-'U� a -----------------------------------------(Title)- � -A <br /> (Plot plan, showing size of lot, location G' system in relation to wells, buildings, etc., can be Placed on reverse side}. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------ -- <br /> - ---- ---------------------------- ------------------------ DATE--------- -----------AX---------- ----------------- <br /> REVIEWEDBY--------------------------------------------------- ----------------------------------- ------------------------------------- DATE------ -----------••---- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------.---------- - ---- ----- <br /> Alterationsand/or recommendations:------------------ -----•-------- ---------... -------------------------------------------------------------------------------------------------------- <br /> ------------------ <br /> ---------- --------------------------------•------- ----•--•------------------------------ ---------------------------._...--•-------------------------•-•-------------------------------------------------------------..----- <br /> ------------------------------------------------ - ------------------ --------------------------------------- ---------------------------------------------------------------------------------------------------•-------- <br /> FINAL INSPECTION BY-- ---------------fm--•------------------------------------------ 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 Revised W-2100 <br />