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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) pate Issued ._9'_- '---j � <br /> „q�.._ ell <br /> Applica+ion is hereby t made to the San'Joaquin Local Health 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 /> ---------------------------------- <br /> .108 ADDRESS AND LOCATION---•-------------�-H�-�--------��-�'�e� ------------------------------------- <br /> �P <br /> Owner's Name------------------•----ILI---------k0cxh ''---•- -•------------------- Phone------------------------------------ <br /> Address........................ ' li -------------------------= <br /> Contractor's Name-"-----•- -------------------------------------- ----- Phone <br /> -------- <br /> Installation will server [Residence <br /> :Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel,❑ Other ❑ - <br /> INumber of living units: -------- Number of bedrooms ---1_7 Number of baths ----- __ Lot.size ------' .7--------- <br /> Water Supply: Publicisystom El Community system C1Private El Depth to Water Table --------- <br /> _.--_ 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 Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.l.. <br /> -Distance from foundation-------_--_---___-_.Material=-----.__ --------------------------------------- <br /> Septic Tank: Distance from nearest well----------------- <br /> ❑ No. of compartments -Size---------------- - Liquid depth----------------- --------Capacity----------------------- <br /> Disposal Field: Distance from nearest well.----------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> Number of lines--------------------------- ------Length of each line------------------------------Width of french-------------------------------.--- <br /> ❑� Type of filter material-------------------------Depth of filter material-----------------------Total length-------------------------------.---------- <br /> ,�F . <br /> Seepage Pit: Distance to _j - <br /> from foundation--..-._--__--_--.-_.Distance to nearest lot line----------------- <br /> ❑ Number of pits-------------------_Lining material----------------------.Size: Diameter------------------------Depth-------------------------------- <br /> Cesspool: <br /> --------------------- ----Cesspool: Distance from nearest well----------------t;Distance from foundation-------------'.--_.Lining material------------------------------------- <br /> ElSize: Diameter------------------------------------'Depth----------------- --------=------------------------Liquid Capacity------------- gals._. <br /> Distance from nearest building---------V- __---_--_- <br /> t r ------ <br /> Privy: Distance from nearest well---------------- ---------�------------- <br /> �. Distance to-nearest 4ot line--------------- ---------------- ------------------------------- ---------------------- <br /> F - <br /> Remodeling and/or repairing (describe):--------------------- - •----------- -- -----------------------------....-------------------------------------------------------- <br /> ' , ------------------------------------------•------------------------------------------------------------------------------ <br /> ____________________ --------------------------------------------•----•--------- ------ <br /> ------ -------------- -"-------------------------------•-------------------•-------------••-------}--------------------------------"-'------••----------------`--•----..•'------------...•-----"•------------------------- / <br /> Ijhereby certify that I have prepared this application and.that the work will be done in accordance with San .Joaquin County <br /> ordinances, State laws,- and rules a d regulations of-the San Joaquin Local Health District. <br /> __.-.--Owner and/or Contractor <br /> ^ - - ---------- ---- =------------------------------------------------ [ / ) <br /> Si ned - - -- -•------- ' <br /> + ----------------­------ <br /> - .., ---------------- <br /> gY�------i:=•----------------------------------•---- ---------------------------------------------------------------------------------(Title}--...------------- -----•--•---------------- <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 /> DATE----------- <br /> APPLICATION ACCEPTED BY------------ `--------------- ----------- ------------- <br /> REVIEWED <br /> --- ...a <br /> --------------------------------•--- DATE.----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------- ------ DATE-----------------------------------•------------------------ <br /> Alterations and/or recommendations------------------- - ---------------------------------------•------- ----------..._...---------------------------.....------_---- <br /> -- -----• ---------------------- ---------------------------------------- <br /> - ------------------------------------------------- <br /> F. ------------•----- ------ <br /> + ----------•----------•------------------------------- ---------•---------------- <br /> -------- ----- <br /> - <br /> ------------------- <br /> f <br /> FINAL-INSPECTION-BY::---��., ► _. - .++ 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 /> E5--9-2M ; Revised W-2100 <br />