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APPLICATION FOR SANITATION PERMIT <br />(Complete in Duplicate) <br />Permit No. <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 16. 549. <br />JOB ADDRESS ANDO- <br />--------- --------- ---- <br />Owner's Name--------------- ---- ---c ------- A. 1 <br />-E- == ------ - -------------------------------------------------- - <br />----------- Phone -----­---------------------- <br />Address -------------------------------------- :�_-i_--- --�-- <br />--------------------- -- - - - - - -------------------------------- <br />Contractor's Name --------------------------------------- �-Q - �'� <br />---------------------------------------------------------------- Phone--- �.1���� <br />Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br />Number of living units: __f--_ Number of bedrooms _1 _- Number of baths ____ Lot size______.�__..�__________________ <br />Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table�ft. <br />Character of soil to a depth of�3- feet: Sand [-]Gravel [:]Sandy Loam ❑ Clay Loam El Clay El Adobe 2 --/Hardpan E]Previous Application Made: Yes �o ❑ New Construction: Yes ❑ No R__� <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />ei(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br />Tan Distance from nearest well ------------------ Distance from foundation __-__-_____-__-_-. Material _______________________________________________•. <br />No. of compartments ---------- ------------ --- Size -------------------------------- Liquid depth ------------------------- Capacity ------- - <br />i � <br />Disposal Field: Distance from nearest well,�0_©----- .Distance from foundation ---- _________f -`:_.Distance to nearest lot line .... ______..__. <br />Number of lines-_____-�______ 7 _�_ De _ <br />p -Length of each line_ D_'____ ____--.Width of trench__ "_--.___-______ <br />Type of filter mal____M'_'Depth r- _th of filter material_.-___�_1}-______Total * length___cx2_ <br />-_Q_'_.-_______-____--.. <br />teria__ _ <br />Seepage Pit: Distance to nearest well__1.Q_D---- ---- Distanc fr f ndation----- ��.�__.Distance to nearest lot line___...?_ <br />Number of its____-. _--.-.-_ Linin material -----------___Size: Diameter-_- __ °' <br />p• ------ g - - � 3--------.Depth--AA 7 --------------------- <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 />F-1 Distance to nearest lot line -------------------------------------- �t - <br />Remodeling and/or repairing (describe):. ""`- ----- `------- ----�—=-'�-j---E ._...1"/?t! �� `----_--------------- <br />------------•---------------------•-------------------------------- -- 1 <br />--------------------------------------------I--------•--------------•-------------------------------------------------------------•----------•--•-------------- ---------------•---------------------------------- <br />I hereby ertify at I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, S+ to la and rules and r ulations of the San Joaquin Local Health District. <br />r <br />( 't!t-----------------------------_--'' <br />(Signed) ------------------------ ------------------------ C'------=--- ---------------------------------------------------------------------(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------------- - ---/3--------------------------------------------------------------- DATE-------- <br />-SZ�-- <br />REVIEWEDBY ------------------------------------- -------------------------------------------------------------------------------------- DATE--------------------- ------------------------------------ <br />BUILDINGPERMIT ISSUED -------------------------------------------------------------------------------------------- ------ DATE <br />Alterations and/or recommendations----------------------------------------------- ----------------------- <br />------------------------------------------------------------------------------- -------------------------------------------------------------- -------------------------------------------•-------------- <br />------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------- <br />-------------------------------- ---------------------------------------------------------------------------------------------------------------- .-.----------- ------------------------------------------- <br />-------------------- ---- - -- - <br />--------------------------------------------------------------------------------------------------------------------- <br />FINAL INSPECTION BY----- --------------------"'--_------------ ------------ ---- <br />Date <br />--------------------------- <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 />