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APPLICATION FOR SANITATION PERMIT Permit No. 1 <br /> (Complete in Duplicate) <br /> Date Issued 5-----------J_*----- <br /> Appliceion is hereby made to the San Joaquin Local Health District for a permit to construct and install the w k herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCAT 0 -------------------------------- <br /> 10 ----------- <br /> Owner's Name------------ V2�------ -- --`--------- F ­ Phone/�4 &"9 _ZK <br /> Address----------------- - --- ----- -- ----- -------- - --- ---------- --- --------------------------------------------------- <br /> Contractor's Name--------_-------------------------- ---- ----------------- --------------------------- -- ----- ----- Phone----------------------------------- <br /> Installation will serve: Residence A rtment House F1 Commercial L] Trailer Court L] Motel E] Other [] <br /> Number of living units: -)----- umber of bedrooms -a- Number of baths --/--- Lot size ------I_0---6--/.r-/- y--------- <br /> Water Supply: Public system Community system' E] Private Ej- Depth to Water Table X - ft— <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [] G+6y­Loam 0 Clay Ej Adobe 0,-<dpan <br /> Previous Application Made: Yes Ej No E] New Construction: Yes No [A <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- <br /> No. of compartments------------- ------------Size----------------------------:---Liquid depth----------- --------------Capacity----------------------- <br /> 57 <br /> Disposal Fie! Distance from nearAt well --------Distance from foundation--- _6----------Distance to nearest lotjine--,-:----------- <br /> 757 .e <br /> Number of lines_- Length of each line_______-0-'-*__------Width of trench----------<----- <br /> 7-------------- <br /> ------------------- <br /> Type of filter materia ff- eck -Depth of filter material---- length-------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____._____.__-_- �1 <br /> ❑ <br /> ine----------------- <br /> 11 Number of pits----------------------Lining material-----------------------Size: Diameter---------_-------------Depth_.---.----.--------------------- J <br /> Cesspool: <br /> epth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation, ---,____.Lining material-------------------------------------- <br /> El Size; Diameter-------------------------- - ------- Depth--------------------------------------------- ------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------__.____________---__--________ <br /> ❑ <br /> uilding ----------------------------------------- <br /> El Distance to nearest lot line- ---r---------- -------I <br /> Remodeling and/or repairing (describe):----- ----- <br /> - ----------- - -- _a -------------- <br /> - -------------------------/-----------------1___1__, ------- <br /> ---------------------------------------------------------------------------- ------------—---- ----- ------------ ..... -- ------------------------ ------- ------------­--------------------------- <br /> ------------------­------------------ ----------------------------­------ --- ----- - ------- --- ------ ------------------------------ <br /> -------------------------------------------------------------------------------- ----­--------------------------------------------------- <br /> ---------------------- ----------------------------------------- <br /> I hereby certify that I have prepared this applicatio and that +he; work will be done in accordance with San Joaquin County <br /> ordinances. State Vlaws, nd rules and-regulations of the San Joaquin Local HealKthisfrict. <br /> -- --- --- ----Own and/or <br /> (Signed)- ------ __/---- -- - Contractor) <br /> —vrr---------- ----------------------------------------------------- <br /> By:---------- ------------- ---------(Title)-- -----<:3 ------ --------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ ----- - ------------------------------------------------------------------------------ DATEz4—-------------------------------------------------- <br /> REVIEWED BY-------------------------- - - -- --­-------------------- DATE ------------------------------------------ <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------- ----------------------------------I----------- <br /> Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------11�_ <br /> --------------------------------------------------- <br /> ----------------------------------------------- ----------1-11--------- ------------ -------------------------------------------------------­----------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------I---------------I----------- ------------ ------------------------------------- -------------------------------------------- ------------------- -------------------------I------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> FINAL INSPECTION BY:._.___.._____. ------------ Date------------ ---------------------•--•--- <br /> SAN <br /> -----------I------ <br /> ------ ---- ---------- -------------- <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 />