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.. ,. _ -.., "'�"�f t•��:qx rya--..:.:..,w � ....�,. <br /> APPLICATION FOR SANITATION PERMIT Permit No- ------------------------ <br /> (Complete <br /> -- --------- <br /> (Complete in Duplicate) <br /> Date Issued /Q <br /> Application 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 ADDRESSdZI-04 <br /> TION- _°�1: --'►'-L'.'9.'�'�-- <br /> Owner's Name---- --- -'�- ------------•---•-------------- - - ------ ----------------- ----- --- 44 <br /> Phone <br /> 3---'- ------- -- ------------------------------------------------------- -- <br /> Contractor's Name------------------------- ---- ----------------------------- ------------------------------------------ -------------- Phone--------------- ----------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motgl ❑ Oth F]Number of living units. .._'___ Number of bedrooms ---2 Number baths __f�/__ Lot size -_1_._3 a,x....Z_�3 ----------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand D Gravel ❑ Sandy Lo24No <br /> Clay Loam ❑, Clay E] Adobe E] Hardpan <br /> Previous Application Made: Yes E] No [ New Construction: Yes ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public fewer is available within 200 feet- / <br /> Septi ank: Distance from nearest weli_s �?_____-Distan fro ifoun tion.__�4_ -------Mater _____ ____ ________ _ Q.� /r______.. <br /> No. of compartments--______-__!_�__•-_t---Size--- k..�_x_S _Liquid depith_________�__________Capacity1___{t`_SL_l ___ <br /> --- <br /> DisposeField: Distance from nearest ell t5r ---Distance from foundation - Distance to nearest lot 'ne. <br /> Number of lines___________ ength of each line_______ .Width of french-,-,,,-.,--_,_ ------- <br /> r __ <br /> Type of filter material_ -_____ th of filter material_____ ---------Total length-___.._ _ - > <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation___ _---:-.Distance to nearest lot line._:­------------ <br /> El <br /> ._.-.__-____❑ Number of pits---------------------Lining material-------------. ------Size: Diameter--•---------------------Depth---------------------------­--- <br /> Cesspool: <br /> _-____---Cesspool• Distance from nearest well----------......Distance from foundation--------------------Lining material-------------------------------------- <br /> r-1 <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 <br /> - - ------ ---------Remodeling and/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, Silije laws, and rules and regulatio of the San Joaquin Local Health-District. --S <br /> J(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... <br /> L <br /> ----------------------------------------------------------------- ------------------- DATEQ _-------------- ----- r <br /> REVIEWED BY---------------------- ----- ---- ------ ------------------ DATE ,�- - <br /> BUILDINGPERMIT ISSUED-------- ------- ------- -------- -------------------------------- --------- DATE.... . ... ------.--------------- ------ <br /> Alter ions and/or recommendations---------------------- -------------------------------------------------------- --------------------e---------------............................... <br /> ------ ----• --------------- ------ --------------------------------- ----- -t - - - - -- --- <br /> --------- ---- - - ---- ---- - -- -- ---------- ----- <br /> -- ---- <br /> ---- ----------------------------------------------------------------------------­ ------------ . .._. a�.�i <br /> FINAL INSPECTION BY--------------•--- ------- -- --•---------------- --------- Dater------ .......... <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 8-51 Revised W-2100 <br />