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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued --- <br /> Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and insfall,the ork herein described <br /> This application is made in compliance wit oun)y Ordinance . 549. <br /> JOB ADDRESS AND LOCATION- <br /> (— -- -------- ---------- <br /> Owner's NarrA-)--- <br /> - -- ------------- --------A----------------- Phone-, <br /> Address- <br /> -- ----- - - -------- - ------------------ -- ---------- - ----------- --------- <br /> -.,:n............. <br /> Contractor's Name----- ---- - -- ---- ---- - ------ --------------------------------------------------- ------------ <br /> Installation will serve: st ante Apart ease [] Commercial El Trailer Court ❑ Motel ote ther ❑ <br /> Number of living units: _/----- Number'of bedrooms —2-- Number of baths <br /> Lot size --- <br /> a <br /> Water Supply: Public system E] Community system F-1 Privat Depth to Water Tablenc7,0 ft. <br /> I <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Clay Loam E] Clay El Adobe E] Hardpan E] <br /> Previous Application Made: Yes ❑ No New Construction: Yes" <br /> V No Fj <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pu"61ic'sewer is available wifhin.02001eet.) <br /> Septic Tank- Distance from nearest ---Distance from foundation---- .........Matprial--- <br /> ---------- <br /> No. of comparfmenls-..�----------------Size_(;r�l Liquid depth - - ---------Capacity----- <br /> _-Disoosal Fie d: Distance from nearest well_......... -----Distance from foundafion_:_-----------------Distance to nearest lot line_-_______________ <br /> W Number of lines___--------------------------------Length of each line-------------"--------••- ----Width of trench.-----._------------_.---- <br /> Type of filter material------------------------ _ <br /> Depth of filter material-- ,- ---------Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well----- - --------------Distance from foundation-'-" 1�----------Distance to nearest lot line_____-___-______ <br /> ❑ <br /> ine----------------- <br /> El Number of pits----------------------Lining material------------------------Size. Diameter------------ ----------Depth--------------- <br /> ------------------ <br /> Cesspool: Distance from nearest-well-----------------Distance from foundation------------------- Lining material__________.__-------------------- <br /> [2i4mefqr------ - De h <br /> Liquid..uid-Capacity ------7­9FIS' <br /> Privy: Disfanc�_fr_orn nea`resf7,,,elJ.___. -------------------------------------Distance from near'esf building___________________________------- <br /> ❑ Distance to nearest lot line__ ______________________`'_. ___--__'I <br /> -- - --------------------------------------- ------------------------------ ----- ------------- <br /> Remodeling and/or re`a' <br /> P 1 9 (describe):----- - -- - -------, ___1------ <br /> ---- ----------------- <br /> ------------ ----------------------'---------- ----------- --------------­--------------- --------------------------k_:----------- ----------------------------------- <br /> - ----- ------- --------------- <br /> --------------------------------------------------------------------- -----I----- ------------------ -------------------- ------------------- "N <br /> ----------------- -------------------------------- -------------------------------------------------------------------------------------------- ---------------------------- -----------------------------:_­------:- <br /> , <br /> .; F NZ) <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 I nd rul nd gulaflons of the San Joaquin Local Healtk-!District. <br /> (Signed)_.__----------- <br /> --------- --- ---- ------ ----1�-------------------------- ---------------------- <br /> ---------- -- ­ -(Owner and r Contractor] <br /> By:---_--------------- -----------------------------------------------------------------------{Title)--- --- -- -- ------ <br /> -- ----- • ----- -------- <br /> (Plot plan, showing size of I location system in relation to wells, buildings,�efc.., can�6be reverse i e <br /> r Side <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- - - ---------------------------­----------------------------------------- --------------- ATE-C% <br /> REVIEWED BY---------------L-- -— - — — ___ ----------------------------- <br /> - -- —- ------------------------------------------------------------------------------------- DATE---- <br /> -- ------------------------------------ <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------=Q\ <br /> Alteratioris and/or recommendations:------------------------------ ---_---------------------•--------------------------------------- f r <br /> ------------------------- <br /> -------------------------------------------------------------- <br /> ------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- <br /> -------------I------------­----------------- <br /> - ---------- ------------------ -------------------------I----------------------------1-1---------------I----------I---------------I-------------------I---------------------------- <br /> -------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------- -------- - <br /> ----------- <br /> ----------------------------------------------------- <br /> - <br /> FINAL INSPECTION BY: 67 <br /> -- ------------------------------------ -- ----------- Date_ : ..... <br /> .... -------z� <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 />