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5 APPLICATION FOR SANITATION PERMIT Permit No. `------------- <br /> (Complete in Duplicate) <br /> y� � V Date Issued <br /> Appli ation 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?rdinanc No. 549. <br /> JOB ADDRESS AND00 OCATION----��--V --------- 0--I/-------------------------------------------------------------------------------------------------------- <br /> Owner's Name '*-QDD yV� Phone S `'�'7 <br /> Address------------------•. P72 b$ . .....) 14—t.� 1-------_--- ---------------------------------------------------- <br /> Contractor's Name------. ---------•-- _- ---------------' "' --•------------•---------------------------------- Phone---y--�G'Z (°--------- <br /> Installation will serve: Residence (( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: .___ Number of bedrooms ._Z' Number of baths __/.. Lot size ....4A-e -__________________ <br /> Water Supply: Public system I Community system ❑ Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cl Loam ❑ Clay El Adobe ' Hardpan [] <br /> Previous Application Made: Yes E] No x New Construction: Yes F] Nok <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ...•••////// ������ <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> �4 eirrk: Distance from nearest well_________________Distance from foundation-___-____- ____-___.Material_-____-___________-______,___---___-_-_-_____._-.� <br /> No. of compartments--------------------------Size--------------------------------Liquid dept--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well---MAt—k-Distance from foundation-------- to nearest lot line-_ �.. <br /> Number of lines----_-_--/___________________Length of each line__________-__--________-Width of trench______ -�,���._-_________._. <br /> Type of filter materiaLIT.l�9�1�-------Depth of filter material_____l _" ______Total length__________--4_______...._____________ <br /> i <br /> Seepage Pit: Distance to nearest well_._N.1_V4-----Distance from Rfo ndation._,,-5r. __.Distance to nearest lot line__�S_._..._ <br /> kNumber of pits......- -------------Lining mate ria __-Size: Diameter--------3_4.--------Depth----------- ____________� <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 /> Remodeling and/or repairing (describe):--------- ---------------------------------------------------------------------------------------------................................................. <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 regulations of the San Joaquin Local Health District. <br /> (Signed)----------- ----; •. -------------------------- ------------------ - (O*or and/or Contract <br /> BY� - - - (Title) <br /> ---- ---- - - - ---- - --------------------------- <br /> (Plot plan, showing size of lot, locatio f system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ---------------------------------------------------------------------•--------------------- DATE--r'---------•------------------------------------------- <br /> REVIEWED BY ---- -- DATE <br /> ---------------------------- <br /> BUILDING PERMIT ISSUED.............---------------------------------------------------------------------------------------- DATE------------ <br /> Alterations and/or recommendations:---------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------- -------------------..................................... ------------------ <br /> •--•------------ -----•------------------•------------ -----------------------------------------------------------------------------------------------... ---------..._..----------------------•---......... <br /> --------------------------------- ------- -------------------------------- -- <br /> FINAL INSPECTION BY-------------- ---------------t. --------------------- Date--------- -( -� 3--------------- <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 /> ESS-9-21v! I0-52 Revised W-2100 <br />