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APPLICAT1Ojj..FOR SANITATION PERMIT Permit No. :�/ `3 <br /> ' <br /> nL (Complete in Duplicate) t, <br /> Date Issued �� ____. <br /> Applica+ion is hereby made to the San Joaquin Local Healt}i'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 /> JOB --m ------------------------- -- -----------------•--- <br /> JO$ ADDRESS ANDAION. -- __. ___ <br /> ------------------------------------------- <br /> Owner's Name------ -------- �`'------------------------------ - -------------------- Phone -- <br /> Address l _ . <br /> ------------------------------------------------------------------------- <br /> ,,�� <br /> Contractor's Name ' -�"'---------------------------------------------------------------------- <br /> _ Installation will serve: Residence R-`Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> r-•---- - <br /> Number of living units: :__.- Number of bedrooms ___ Number of baths J.... Lot size _� _- -___ <br /> Water Supply: Public"system �ommunity system ❑ Private'❑ Depth to Water Table _3�v ft. <br /> Character of soil to a depth of 3 feet: Sand ❑, Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No [ New Const ction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: / <br /> I (No septic tank�or cesspool permitted if public sewer isavailablewithin 200 feet..)} /�y <br /> Septic Tank: Distance-from nearest well-----�----Distance from foundation-__-/D________.Material__�' 1__'__�°__-✓�°x ---- ,----�. <br /> No. of compartments-------pAL------- ----Sizer. -__ iquid depth-----;Z(o__ ........Capacity._I'vG " \ <br /> � r lines.__rest well___________ _____ _ <br /> _ Distance from foundation------------- to nearest lot line----------- <br /> ❑ Number or <br /> Disposal Fie Distance from nearest -Width <br /> Length of each line____________________________ of trench____-__.________________________- <br /> Type or filter material_'-----------------------Depth of filter material-----------------------Total length_°____________-___-________________._ <br /> See a e.Pit: "T Distance to nearest well ________Distance fro -fou 'dation R_ <br /> pQ__.____.Distance to nearest lot line__`l .- <br /> Number of pits.____./_____________Lining m'at'fia1L+?±_�_�_ � :Size: Diameter----�7_t3.....-___Depth......��-�-______._______ <br /> Cesspool: Distance from nearest well---_-------------Distance from foundation <br /> ------------------- material___._._____________.________________. ` <br /> ❑ Size: Diameter---------------------------------------Depth............-------------------------------- ` Li uid Capacity----------------------------gals. <br /> I Privy: Distance from nearest well------------- ______________________________Distance from nearest building_________.-------____________-___________- C" <br /> ❑ Distance to-nearest.lot line-=_::_..:______ - -� 1►1 <br /> ------ --•------ ----------------------------- <br /> Remodeling and/or repairing (describe): ----� ' .--- ------ --------------------------- '------'-----• ---------• ---•--.----'----4� <br /> 1. <br /> ------------------------ --I--------------.--------------------- ----------------------------- <br /> ------------------------ 4 ; •---------- _- -------- <br /> ----••------ --•-•-----•------- . --------•------•-----------•- <br /> -------------------------------------------------------------------•------------------- <br /> i 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 1 s, and rules and regulations of the San ,Joaquin Local Health District. <br /> __._ _ and/or Contractor) <br /> (Signed)----------------- ---- t"t..... . ---------------- <br /> ' �Y� ------- ------------{Title)--- -- -------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> J _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_-------------------------------------------------- ______________________-- DATE_ ______..___- . -- <br /> - ---------------- ------------------------ --------- ------- -- <br /> •------•-•------------ ---------- <br /> REVIEWED BY - DATE---- <br /> BUILDING PERMIT ISSUED------------- -•----------------------------------------------•--------------.._-.----•-------------._ DATE..........v----- <br /> Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------­------ <br /> ----------------------------------------------------- --------- -------- --------------------------------------------------------------------------------=------------------------ •-•------------------------•.............. <br /> 1 <br /> - .. -------------------------------------------------------------------------------------------------------•-------------------------•----- <br /> i •----------------------------------•---`-------••---- ------------------------------------------------------------____--------------------------------------------------------------------------------------------------- <br /> F . <br /> ------------------------------------------------------------------------- -- -- ---- ----- ---=------------------------------------------------------------------------------------------------------------•--------------- <br /> FINAL INSPECTION-BY:------' --_ = Date--------- -------- <br /> --- <br /> ----- -"= 1� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; ' Revised W-2100 <br />