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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) ,��f <br /> Date Issued __ 0�'` <br /> Ap ' a+ion'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. 549. <br /> JOB ADDRESS AND LOCATION.,... �.................. 7 <br /> --------- -------- <br /> - ------------- --------------------- a <br /> r <br /> Owner's Name---------------------------- A------- -- ------ Phone----- <br /> -- --------------------------•--- <br /> Address----...-----•------•------------------•-------••--•----. <br /> ............................................................................................................................ . <br /> Contractor's Name------------------------------------------------------10,4_11-4----•-- ... ---------------------------------------------•------------------ Phone----------------------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ tel ❑ Other ❑ <br /> Number of living units: ________ Number of bedrooms -------- Number of baths -------- Lot size ........ <br /> Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table �P_ 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 �o ❑ New Construction: Yes ❑ No Ge <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 /> ____________.____________..____..____.___.__.___. <br /> ❑ No. of compartments-------------------------Size----_------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> r_1 Number of lines___________________________________Length of each line---------.--------------------Width of trench._____.______.___________._...__... <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well______----------------Distance from foundation___.-_-_-__-___-__-.Distance to nearest lot line--------------_-_ <br /> ❑ Number of pits______________________Lining material-----------------------Size: Diameter--------------.---------Depth--__-_.__-__-_____-_-_•__ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------- <br /> F1Size: Diameter------------------ -------------------Depth----•--------------------------------------- <br /> Liquid Capacityt----------gals. �... <br /> Privy: Distance from nearest well-------------------f�_�_.__.__.___.___Distance from nearest building..:___.______�_ ----------•------- <br /> [ Distance to nearest lot line . <br /> Remodelingand/or repairing (describe):......................................................................................................................................................... <br /> ------------------------------------------------------------•-----------------------------•--------------------------------------------------------------------------------------------------------•----•------•------------- <br /> -----•-------•---------•-----•---•------•-•---------•--------•-----------•------------•-----------••---------•------------------•---------------------------.--- •-------•- <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 and regAafions of the San Joaquin Local Health District. <br /> i <br /> ----------(Signed / ---------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:.............................................................................................-------------------------------------(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 /> APPLICATION ACCEPTED BY--------------------------- - - -- --------------------------------------------------------- DATE----------- <br /> REVIEWED BY------------- <br /> ------------- ----------------------------------------------- <br /> f <br /> DATE - <br /> BUILDING PERMIT ISSUED------------------•---- ------ DATE--------------------- <br /> Alterations and/or recommendations: ........ <br /> ---------------------------------------------------- - - ;F '6 -�----------------------------------------------------------------•--- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------- -- <br /> - ------- <br /> ----------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:.---------- _fi_. Va'?-------------- Date------------------ <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 />