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APPLICATION FOR SANITATION PERMIT Permit No. -A---- -----------­- <br /> (Complete in Duplicate) Date Issued <br /> Application is hereby 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 5491. <br /> JOB ADDRESS A LOCATION---; _ __Atl-----�2 --- ..... <br /> --- --------------- -- -------------------------------------------------------------- <br /> Owner's Name - ---- --------- ------- --I----------- ---- Phon _/-7- <br /> 7- <br /> Address..Q...4-- ----- ----- <br /> ------ <br /> - -----------­------:T!Tt-------------------------------------------------------------------------------------------- <br /> Contractor's Name_ - 4 VY 0 <br /> -------- - ---------------------------- AP17ne ----- -------------------------- <br /> - <br /> Installation will serve: Residence E] Apartment House ❑ Commercial Trailer Court ❑ Motel El Other El <br /> Number of living units: -------- Number of bedrooms -------- Number o aths'*-.--- Lot size ------------------------------------------------------------ <br /> Water Supply: Public system E] Community system El PrivNumber <br /> to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe 20-.-Hardpan L] <br /> Previous Application Made: Yes L] No M/ New Construction: Yes [9 No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if ublip sewer available within 200 feet#) <br /> from ----�isfan(;e from fSodation/---.----------- <br /> Se nk: m ra t'e—, ,I --------- ---------- <br /> "y------Cl- <br /> Septic <br /> No. of'tom parfrrients-- ------siz --------Siteql;) ...... ._-S.Liquid 0epth------------ ---- --------Capacii vV <br /> D;sposal°Fielcl: Distance from nearest j rstancep e* _ ___ _, ___ .Li <br /> ",nda ionl A9__ istance to nearest 110t I' <br /> 11------------- <br /> Re Number o-i' lines.-:-------- ......I--------- - Length of each line---------------- --- Width of trench.-.//- 0---- --------- <br /> Type of filter mater .-M__�_ Op+h of filter material_____ -Total length_______-. ____________...___-_____ <br /> Seepage Pit: Distance to nearest well-.-.-t------ --------Distance from fou'ndation--------------------Distance to nearest lot line----------------- <br /> F1 Number of pits------------------- -Lining material----------------------.Size: Diameter------------------ ----Dept h-----1---------- --------- ----- <br /> j <br /> Cesspool: Disfance from nearest well:_________._ Distance from' foundation---------------------Lining material----------1__---------------------- <br /> El Size- Diameter------------------ <br /> 'i� ....................... ... <br /> .. .I.... <br /> D..i.a..m..;e-A-t-e--rr------- <br /> --=------------------------------ ------- <br /> --------------D- e--p--th---1--------"-----_-------_-------------------L---1---1-:--V---------------i--r-------------------------------------------L-i-q---u--id------C----a--p---a--c--i-- <br /> t--y------------------------------------------------------------------------------------------ <br /> -------g------a------l---s---- <br /> - <br /> - <br /> . <br /> Privy istoncer"rom-nearest wed------------------------------------ --------.-Distance from nearest building-------------- -------------------------- <br /> EDistance-to-nearesf-lot-lino -- ----- ---- -- -- ------- <br /> RemodW11n- U . peiri4dl$c�ibe - --------I --- - ----------A-0------------------------ <br /> --------- .... - - 4 <br /> ----------------------------I--------I------------------------- ---------------------- ------------------------------- -------- -­-­------­------------- -----------------------7­-------------------------------------- <br /> ------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 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 laws, and�rules a�dregu;latfions, of the San Joaquin Local Health District. <br /> (Signed)- - ------- --- ------ - ---- - --------- -----------------------------------------------------------------------------(Owner and/or Contractor) <br /> &041�01_r <br /> I------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------------------------------ -- <br /> 10 <br /> (Plot plan, sho i;191 size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ------------------------------------ ------------------------------------ DATE�� <br /> --- ------- ------- --- i;x--------------------------------------------------- <br /> REVIEWEDBY---[------f--------------------- -------- ------------------------------------------------------------------------------- DATE--- v�-------------------------------- -------------- <br /> BUILDINGPERqIT IiSUED---------------- -- --------------------------------------------------------------------------------- DATE--------- ----------------------------------i----------- <br /> Alterations and/or recommendations:______..,_:_------ - - <br /> .....�­---------; ........ --- ----- ---- -------------------------------------------------------------I--------------------------- <br /> --------------------------------------I--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------- ------------------------------------------------­---­------I------------------------------------------------------ <br /> ---------------------------------------------•----------------------------- -----------------------------------------:------------------------------------------------------------------------------------------- ----------- <br /> ---------------------------------------------- --------- ---------------------------------------------------------------------------------------------------------------------- <br /> --------// ------------------------------------------ <br /> FINAL INSPECTION BY----------------- Date--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Sfroo+ 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manfeca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2= <br />