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APPLICATION FOR SANITATION PERMIT Perrr�,it No.�-�__�._.�__ <br /> (Complete in Duplicate) v <br /> Date Issued�!P/J---�V/f", <br /> Application is`kerTy made to the San Joaquin Local Health District for a permit to construct and install the war herein described. <br /> This application is made in compliance with County Ordinance No. 54 <br /> JOB ADDRESS AND LOCATION---.....�,/--------- -- ------------------- = <br /> Owner's Name----------------•--- __.r ....-----?----------- - ----------------------------------------- Phone------------------------------------ <br /> Address------ ------- f <br /> - ------------------------ - <br /> Contractor's Name �.. -------- ------ - ----- -- Phone-- —f_ - <br /> _ <br /> k Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot I ❑ Other ❑ <br /> G Number of living units: _.�--- er of bedrooms _Z.Number of baths __/__ Lot size ._ __--. / __ "'---____ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> i Character of soil to a depth of 3 feet: Sand ravel [❑ Sandy Loam ❑ lay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> � Previous Application Made: Yes ❑ No UKNew Construction: Yes No ❑ <br /> i 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 /> 6_C%. t o. of compartments--------------------------Size------------------ __Liquid depth______________------______Capacity <br /> Disposal Heid: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line______________... <br /> ❑ / umber of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- r { <br /> Type of filter material-------- ------ epth of filter material_-________________:---Total length__....--------------.---------------------- - <br /> Seepage P' Distance to nearest well . V___ _-- Distance 0 , fQunddtion_. �-:--- <br /> � ...___.D' nce to nearest lot line <br /> Number of pits---- __ _ ►___Lining material- <br /> ize: Diameter-_ ______________Depth_--�_Q__________________ <br /> Cesspool: Distance from nearest welL________________Distance from foundation-------------------- material_________._-____--_-___...._.._..__--- <br /> ❑ Size: Diameter- - Depth----- ­------------------------------------------------- Liquid Capaci ----------------------------gals. I <br /> Privy: Distance from nearest well_________________ ___________. _____ ____Distance from nearest building____________._________________.__________. <br /> r ❑ Distance to nearest lot line------------------- ---- ----------------------------- <br /> i t <br /> Remodeling and/or repairing (desc�b a --- --------- - --------------- �_. --------- <br /> 4 --------------...._........----------•__••_________� ---------------------------------------'---------------------" -----------------'._____________..»....-.__----- <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 and regulatio s of the San oaquin Local Heal+h Dis nct. <br /> t <br /> (Signed) .._..�:r ' _ i - "" :. ----- - (Owne nd/or Contractor) <br /> BY: ---------------------------------------------------------------(Title)------ <br /> ---------- ------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed <br /> -on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ------------------------------------------------------------------------------------------ DATE- <br /> REVIEWEDBY-------------------------------- ------------------------------------------------------- DATE "� ---- <br /> BUILDING PERMIT ISSUED------------ ------------------------------------- DATE <br /> Alterations and/or recoinmendations:------------------------- _i'-------- <br /> ------------------------------------------------------ <br />' ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> i <br /> ---------------------------------=-------------------------------------- ---------------------------------- ------------------------------------------------------------------------------------------------------------------- <br /> P <br /> ------------------------------ <br /> i --------------------------------------I-------------------- <br /> ---- ------------------------------------- <br /> � i <br /> FINAL ,INSPECTION BY: ` Dare <br /> 6 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> ii Stockton, California Lodi, California Manteca, California Tracy, California <br />} ES---9-2M 8-51 Revised W-2100 <br />