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�\s <br />` \ APPLICATION FOR SANITATION PERMIT Permit No. b._ -1.... <br /> y�\ \ (Complete in Duplicate) <br /> Date Issued ..___7 <br /> ._�. ��. <br /> Applica*ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herei scribed. <br /> This application is made in compliance with County Ordinance No. 549 <br /> JOBADDRESS AND L�O,QATIO ...... ------------------------- -- --------------------------------------------------- ------------p--------------------- <br /> Owner's Name------------ /1 .--- - -- ---- --- ------ - --••-------•----••-•-------•------------------••------------------•---•----- Ph _--.Q-.�.�"....-- <br /> Address <br /> ------------•-------------------------- -e---------I--D-- <br /> - <br /> ------- <br /> Contractors Name P � <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mojel ❑ Other ❑ <br /> Number of living units: __l____ Number of bedrooms •Z___ Number of baths I_.. Lot size __7 _X_14d__-_-_•________________________ <br /> Water Supply: Public system (Community system ❑ Private ❑ Depth to Water Table .Yd ft. <br /> Character of soil to a depth of 3 feet: Sand E]Gravel Sandy Loam Clay Loam ❑ Clay C] Adobe Hardpan ❑ <br /> Previous Application Made: Yes E] No <br /> New Construction: Yes o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic ank: Distance from nearest well-----7777:�----Distance Nfrom <br /> _foundation.... -------Mater--i I.. �_ ----- _.. <br /> No. of compartments_.-----A--------------Sizc.SA3/'/ _._..:_-.Liquid depth -- -.__..-__-Capacity_.. O---_ <br /> ___ <br /> 193 <br /> Dispos Field: Distance from nearest well------`---___--Distance from foundation___s, d._..._.Distance to nearest lot linej___-�....... <br /> [� Number of lines----------- ______ ______ __Length of each line._..�_Q__... _-......Width of trench....cA.Y-._._--._ <br /> ----------- <br /> Type of filter matenal�/a____ ________ ___Depth of filter material_______-____-______Total length.... __..__-_____..._.___...__.. <br /> Seeps Pit: Distance to nearest well___"_'"_---------Distance ffrJm oun ation...�r^ ........Distance to nearest lot line.__` <br /> SX� <br /> Number of pits------�...__.____.r_Lining material__�+__�r__ _______ Size: Diameter______________________Depth---o�s____._______..._____ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material_____-_-.._-._.__-____-____-____-___-. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------•----------.Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------.______---------_--__-._._. <br /> ❑ Distance to nearest lot line----- --------------------------------------•-----------------------------------------•-----------------•----------------•-•-----•---•--••--- <br /> Remodelingand/or repairing (describe):------------------------------------------------------------------------------------•---------•-----------------------------------r•---------•-------- <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, nd rules and regulations of the San Joaquin Local Health District. <br /> (Signed)................ - - 4 ------------------------------------------------------------ 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 /> REVIEWEDBY---------------------------------------------------- --------------------------- ------------------------------------ DATE........................................................ <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------........................ <br /> Alterations and/or recommendations:.--------------------------------------- -------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••----------- <br /> ------------------------------------------------------------------------------------------------------•------•-------•-•----••--...--••-•-----......------••------------•-------............................................ <br /> ------------------------------------------------------•-----.-__--------------------------_-...----------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------- -•-------• ------------------------------------------------------------- -----------------------.................................................... <br /> FINAL INSPECTION BY:. L-------•--- ---------­----- Date_--------------------......................-------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street e14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W2100 <br />