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APPLICATION FOR SANITATION PERMIT Permit No. •..k Z:_3.1 <br /> 42-1 (Complete in Duplicate) TJy �'s <br /> 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 /> JOBADDRESS AND LOCATION---------A---------------4_ ---- - -----------------------------------=------------------------------------------------------------------------- <br /> Owner's Name-------------�.%� ' ------?_74:e ----- I •---•------ -------------------------------------------------------------- Phone--------------------------------- <br /> S ------------------------------------------------------------------- --- ---- <br /> - ��- -- - ------- <br /> --•✓-`---�lo�� <br /> Address , ----------- <br /> Contractor's Name-------__-• � � Phon / --------•--------•- <br /> Installation will serve: Residence aro"A-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: I___ Number of bedrooms ---� Number of baths I___ Lot size -----------------­- <br /> Water <br /> ________________Water Supply: Public system ❑ Community system ❑ Private 200'Depth to Water Table y 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 VRO'O'No ❑ 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 Ta Distance from nearest well-J.4-16 ----Distance from four dation. l� Mate�al_ C' --- <br /> No. of compartments_.____O2L---------______Size___-_X. d__-.___,__-Liquid depth____y,/y---------Capacity..... <br /> Disposal Id: Distance from nearest welLlO�--------Distance from foundation._Ze_...__.Distance to nearest lot line..1Q.._...._ <br /> 9,0110 Number of lines.....________ _____________-Length of each line..... 7A------------------Width of trench___�_rz_�__.................... <br /> Type of filter materials'-)Rc,_k-----Depth of filter material_____.Ik_........Total length-----3-a_............................. <br /> Seepage Distance to nearest well-1—_--_______Distance jrom foundation---/ .........Distance to nearest lot line__/j............ <br /> Number of pits___ - Lining mate ria l_6,_, Size: Diameter---34-•----------Depth_____ .r/__-_---______._ f ; <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 /> ElDistance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------- <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 <br /> ssand regulations of the San Joaquin Local Health District. <br /> �s o - Aote_&- -------------4on <br /> wn and/or Contractor) <br /> (Signed)------1-/----- ---- -- --------- ------ -- -- -- ----------------------- <br /> -- - .c --� .� `----.' i�-------------------------------------- -----(Titlippaced <br /> (Plot plan, showing size of lot, location of stem in relation to wells, buildings, etc., can beerse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY----------------- --- --- ---- ------------------------------------------------------------ DATE------ca,, --------_--------------------................ <br /> BY--------------------------------------------- ------------------------------------------------------------ DATE...... - - <br /> BUILDING PERMIT ISSUED DATE7\_ _ -- <br /> -------------------•------------------------------------ <br /> Alterations and/or recommendations:______.___.----- . ----� <br /> ----------------------------------------------------------------------- ----------------------- ------- -----------------------------------------------------•-------------------•--- .-J------------------- <br /> 1 <br /> __----.--_•_______________•-----------------------------.-_-__-___--._._-___---__-....___--_._.-----------..---------------_.._--.______-__-._-___-..--------------------------------------------------------.................. <br /> ----------------------------------_-----------------------_________------------------------_--------------------------_---------------------------___________----------------------------------------------------_-------- <br /> .. <br /> FINAL INSPECTION BY:.-----=:----- ---- -- -------------------------------- Date.-- ------ � r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' u <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 />