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..4 <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> ' Applica+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-----------`_ --_� --- --- -- .--- �`�------ <br /> Owner's Name-------------------- •--•-- ••• ----- ---t a- O Phone. <br /> ----- <br /> Address - - - <br /> � <br /> " <br /> - - - - <br /> ----r----------- Z t.r .... Phone_ .50.Contractor's Name -------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel y❑ Other ❑ <br /> Number of living units: ._.___ Number of bedrooms _, __ Number of baths ---/. Lot size ----- <br /> ....a__0 <br /> Water Supply: Public system ❑ Community system [I Private [y6epth to Water Table J___0 ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam E] Clay ❑ Adobe Hardpan E]Previous Application Made: Yes ❑ No Sand <br /> Construction: Yes No ❑ <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 /> ENo. of compartments---------- --------------Size----------------------------...Liquid depth--------------------------Capacity----------------------- <br /> Disposal Fold: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line................. <br /> Number of lines___________________________________Length of each line------------------------------Width of trench-___--_-------_-___________________ <br /> Type of filter material__________ ___________,-,Depth of filter material-----------------------Total length_______-.__-___-••---___-____-_______--__ <br /> s <br /> Seep ge ' : Distance to nearest well_•_-_______'_Distance f om f undation__Z0. __..-_..Distan to nearest lot line__ ' __.__ <br /> Number of pits__Dt ——_'______Lining mate ria l...___ �__ ------Size: Diameter_--?­3 -------Depth.......o;?- --------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------.----------------------------- W <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 /> 0 <br /> ---------------------------- <br /> ` . <br /> -- <br /> . y <br /> ---- - ----- -- <br /> ---------- --------------------------- <br /> -------------------------•••----•-------------•---•------------ -----------•-------- ------------------------------------------- -------- --------- <br /> I hereby certify that I have prepared this application and that the work wil be done in accordance with San Joaquin County <br /> l i <br /> ordinances, State I s, d rules and reguons of the San Joaq in Local Health Dist r' t. <br /> (Signed) d O �, v --rl (Ownor tractor) <br /> ------------------ - <br /> --- ----- -- -- -------------------- -- 7 ......Title_ k-= •�. <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 /> APPLICATIONACCEPTED BY--- ----------------------------------------------------------------------------- DATE-----��------------------------------------------------ <br /> REVIEWEDBY....... .. ----------------------- ---------- --------•- DATE----------1 -------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------- --- -------------------- .................................................... DATE---------------- - <br /> Alterations and/or recommendations: .... .-•------------------------ <br /> ---------------------------•------------------------•------------------------------------------------------------------------------------------------------------•-----••••--••--•••••-----•--------•----•---------•••.••---- <br /> --------------------------------------------------•------------------------------------------------------------------------------------------- ------•-----------------------------•----------------------------------------- <br /> -------------••------------•--•. ---------------------------------------------------------------------------•---....---••-•••••--•-------------••-------•-------•---......----............. <br /> --------------------------------------------------------------------------------------------------------------- --------------- -----•------------...----------•------------------------------------------------------------- <br /> FINAL INSPECTION BY:•-.-------��..��"-'-'--------_---------------• Date----- _' -.5 .S- ................................ <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 />