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f� <br /> (� �y APPLICATION FOR SANITATION PERMIT Permit No. _ . _..- <br /> `;. <br /> (Complete in Duplicate) Date Issued <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 /> �j <br /> JOB ADDRESS AND LOCATI N__.._ __ ___/ ._ <br /> Owner's Name = �!! ------------ ------------------------------------------ Phone-----•-----_-- ------------------- <br /> Address------------------------------- - - <br /> Contractor's Name --------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence Rr �partment House [-] Commercial ❑ Trailer Court [-] Motel ❑ Other ❑ <br /> Number of living units: J_ Number of bedrooms ---Ar- Number of baths __I___ Lot sizelr­.�----------------------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table . Q 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 ❑ No [H'"ONew Construction: Yes ❑ No Rqi FHA/VA: Yes ❑ No Rg-- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> septi Tank: Distance from nearest well_________________Distance from foundation-:____-_________-.Material------------------------------------------------- <br /> D`_ ' No. of compartments--------------------------Size----------------------•- -----Liquid depth--------------------------Capacity------------•---------- <br /> 4z; <br /> ld: 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 /> Seepage <br /> ______-_________ _-._____•--__-____-__-_Seepage Pit: Distance to nearest well----- —______Distance frpm fou ation....A ____-_-.Di take to nearest loj� line...>�__•.__- <br /> ®+"0" Number of pits_,,.../-___________Lining material/-_,"-Size: Diameter ___________Depth___ ________op______ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------------_________. v <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 /> ,104a------------- ------------•-------------------------------•---- ------ \� <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, anj rules and regul tions of the San Joaquin Local Health District. <br /> (Sine <br /> 9d) -------------- -------------(fawrw w1mver Contractor) <br /> By: ` ---------------------------------------(Title) ,/ <br /> - ---------------- <br /> (Plot plan, showing size of lot, loc n of system in relation to wells, buildings, etc., can be placed on revers ide). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- --------- - •------- -------------- - --------------------------------- DATE.._ <br /> REVIEWEDBY--------------------------------xr� _:--`---.•------------------------------------------------------------- DATE <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---- <br /> Alter tions and/or recommendations: ---------------------------------------------------------------------------------- <br /> - Q' �` - �a t� C. c���l •F'� �Q/Yl�c.c'? - '----------- <br /> iy -------- ---- -- -- ---- .................................__...... <br /> -------------------------------------------------------- ---- <br /> ------ <br /> FINAL INSPECTION BY: ------ Date------ ------� � <br /> PF 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 Revisea 1.57 FP.M <br />