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. <br /> APPLICATION FOR SANITATION PERMIT Permit No. ................... <br /> (Complete in Duplicate) <br /> Date Issued __ __ ______ -------- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herei d scribed. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND L TlON______ _____ ___ _ --�_._ <br /> .- ---- <br /> Owner's Name------ ------ -- •---------- Phone- ------------ <br /> Address---•-•------ --- --------- ........ - <br /> ---------- <br /> Contractor's Name '------ ------ ----------------- Phone -- <br /> .R <br /> Installation will serve: Residence Apartment House ❑: Commercial ❑ Trailer Court ❑ /Motel ❑ Other ❑ <br /> Number of living units: __j___ umber of bedrooms __/---- Number of baths __/__- Lot size .__�z__ _.I _ ---------------___ <br /> Water Supply:- Public system ❑ Community system ❑ Privaterw Depth to Water Tablepft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan E]Previous Application Made: Yes E] NoV New Construction: Yes F] N? �! <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: I <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tan Distance from nearest well_____________ Distance from foundation--------------------Material---------------_---------------------.___-_____. <br /> No. of compartments-- -- - -------- Size---------------------r------------Liqui- epth---------------- --------Capacity--------------- <br /> "Disposal Field. Distance from nearest weIL. D_-_Distance from foundation_ -- --..------Distance to nearest lot <br /> Number of _______ ___ Length of each line___._ ___M ----- of trench_._.__�l <br /> fType os filter materia ___ -_-_. .---Depth of filter material__:.__._ 7-----___,Total length------ ____________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____...__.______- <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter_`---------------------.Depth---.---•------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation____----------------Lining material-------------------------------------- <br /> Size: <br /> ___ _.._____.__________-___.___.__- <br /> Size: Diameter-------------------------- - DepthA-------I--•------------- ---------------------Liquid Capacity- --_-------:gals. <br /> Privy: Distance from nearest well--------------------------------­_:_ <br /> ___Distance from nearest building ` <br /> ❑ Distance to nearest lot line---_---------------------_----------4----- <br /> = - ----------------------------- ------------- <br /> Remode#ing and/or repairing (describe);---------� �%---_� 4 -, -' <br /> t <br /> ---------------------------------------------------------- <br /> 4 <br /> ------------------------- ---- ---------•---------- ---------------•--------------------------------••-- -----------------------------•--••----------------------------------------------------------- – .°--------- <br /> 1 hereby certify that 1 have prepared this application-and-that-the work will be done'in accordance with San Joaquin County <br /> ordinances, State and s d regulations.-6, the San Joaquin Local Health District. �- # <br /> (Signed)---------- - -•---- ---- -- ------ - --- ---- -- - - ----- -- '-----------------------------------`------------------------ --- O ner and/or, actor] <br /> By: -- -- +�✓i r------ - - ---- - -- - ----- - Title -- •-- W <br /> Y { I ---------- <br /> (Plot plan, showing size o ot, location of system in relation to wells, buildings, etc., can be pl a on reveAssa side). <br />` FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- `�------------- ---------- -------------- ---------------------------------------- DATE_ ' <br /> REVIEWEDBY--------------- ------ ------------------------------------------------------------------------------ DATE---- -------------------' r <br /> BUILDINGPERMITISSUED-----------------------------------•---------------------------------------------------------------- DATE-------- ---(4�>----------•----------------------------•----- <br /> Alterations and/or recommendations:-------------------------- ------- ---------------------------------------------------------•----------------------•---•-------•------------------------------- <br /> i <br /> -------•--------------..----------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- ----------------------- <br /> 5 <br /> _______________________________________________________________________________ _______________________•_--...._-______---_____.._______._______._ p <br /> FINAL INSPECTION BY:--------- ------------- -- Date " <br /> __... --------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> 130 South American Stree+ 300 West Oak Street 132 Sycamore Street 814 North "C' Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> i <br /> ES-9-2M 10.52 Revised W-2100 <br />