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APPLICATION -FOR SANITATION.TERMIT Pe <br /> ! ' rmit No. <br /> (Complete in Duplicate) Date <br /> Issued <br /> A is hereby made to'the San Joaquin Local Health District for a permit to construct and install the' wor herein described. <br /> This <br /> — I Bance;'s application ism -K-Corn with ount Ordinance N . 549. <br /> L <br /> ---- ----- -- ----- -- ------- - ------ ----------------- <br /> JOB ADDRESS �C <br /> ----- ----------- <br /> Owner's e. ...... <br /> ----------------------------- <br /> ­ --------- - -*-------- --------- ----- -- ---- ----------------- ---------------- -- Phoni <br /> a <br /> e -I------ <br /> Address-_ <br /> Contractor's N e--'-- -- - - --- ------ ---- ---- ------- ---- --- - ----- ......... Phone.---------------------------------- <br /> Installation will serve: Resident M00"Apartment House' E] Commercial ❑ Trailer Court E] MOO E] Other E3 <br /> Number of living ---- Number of bedroom's <br /> Number o aths --- Lot size ---- <br /> Water Supply: Public system E] Community system El PriJate530D§V+�h e— <br /> af6r­Tabl __—ff7—'� <br /> Opt <br /> Character of soil to a depth of 3 feet: Sand E] Gravel Ej Sandy Loarn "lay Loam Ej Clay ❑ Aclobe[] Hardpan E] <br /> Previous Application Made; Yes Ej No New Construction: Yes No ❑ <br /> C)o <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if puLZiic gew r is available W Ithin 200 feet) <br /> Se D�stance from neare� -------- istance from founclatio------_---- _---___---,..Material------------- <br /> No. of compartments <br /> st wel L n <br /> -------------- ---------- ------- <br /> --------Size---------- __Liquid-4epfk ` ---------------------Capacity:--- -- <br /> Dis Field: Distance from nearest web 'Distance from f6l_jndation_/05�isfance to nearesf:IoAine 17 <br /> P;� Number of lines-- ength of each line________ 'rf_----.Width of trench.__-____"___ <br /> Type of filter mater _._;A�_-_-­epfh of filter material___-. <br /> - ---=-----Total lengfhl <br /> y' r -------L__V_11-------------------- <br /> - - -------------- 6"f <br /> Seepage Pit:- _Distance to nearest well'- -------Disitan " ,from foundati- Disitanc o nearest lot line--' <br /> CP foundation------------------ ------------- <br /> El Number of pits----------------------Lining ,;gteirialA�4 <br /> ---------Size: Diameter--- --------------------Dept.h--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation _.-- - --_r__._.-Lining material_-_.______________._____--_-_______.❑ i <br /> Size: Diameter------------- ---- -------- <br /> -----------Depth---------------------------------------------------[----Liqu;d Capacity----------------------------gals- <br /> - <br /> Privy: Distance from nearest wO--------------------------------------------------Distance from nearest building_________--____---_-_______--_------_---. <br /> ❑ <br /> uilding------------------------------------------- <br /> 0 -Distance to nearest,'Iof line--"---.------------- . '.. .. -1 . .-• _4� . <br /> -------------------------------------------------------------------------------------------------------------:-------------- <br /> Remo6ling and/or repairing (describe):-......----':---------------==------------------------•-••----------------= ---------I--------------------------------------------------------------------- <br /> ----------I----------------------------------------------------------------------------------------------------------------------------------------------- I------------------------------------------------------------------ <br /> +4, <br /> -------•------------------ 11---------------------------I---------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> t V I. , " 7 - V- <br /> ---------- --------------------------------------------------------------& - <br /> ----------------------------------------------------------------------- <br /> ----------:------------------------------------------------- -------------- <br /> I hereby certify that I have p.repar'ed 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 /> (Signed)----,-*" <br /> ------------------------------------------------------------ -----------------------------------------------(Owner and/or Contractor) <br /> BY:---------------------?...............--•----------=-------------------------------4-------------------------------------- ----------(Tif le)---------------------------*------------------------------------ <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 ---- - <br /> -------- -------------- ------------------------------------------------------ DATE M:? <br /> Z -_ -----------------------------------7---------- <br /> REVIEWEDBY------------------------------- ------------------------------------------------ ------------------------------ DATE-----,`a------ ------------------ <br /> ------------------------- <br /> BUILDING <br /> -------:---------- <br /> BUILDING PERMIT ISSUED---------• ------------------------------------------------------------------------------------------- DATE-, :;i N <br /> G <br /> -------- -----------*---------------------------------- <br /> Alter6tionsand/or recommendations:----------------------------------------------------------------------------------------------------------------- ----_. --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------*--------------------------"I <br /> --------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------I------------------------ <br /> 7 <br /> -----------------------------------------------------------•----------•------------ ----------------•-------•----•--------- <br /> p l , <br /> I=INA!* <br /> -------------------------------------------*--------------------------------------------FINAL—INSPECTION $Y:. - <br /> ------- �sa <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 ; . Revised W-2100 <br />