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1 APPLICATION FOR SANITATION PERMIT Permit No. t_`f_ c)___ <br /> (Complete in Duplicate) ff <br /> •��� �.� ., �.� ,... , - bate Issued <br /> Applica{ion is hereby made to the San Joaquin Local-Health Distr ct forZ mo construct and install the work herein described. <br /> This application is made in compliance with County Ordinance 49.s- <br /> JOB ADDRESS AND LO A 10,..... = z _1 <br /> ---G� I Phone e d� ---------------- <br /> Address <br /> Owners Name .��` <br /> f -------------- ------- - <br /> Address-------------------- ---• - -------� ----- ------------- <br /> Contractor's Name--------------------- Phone._-. <br /> ..--•-------- <br /> Installation will serve: Residence [Apartment.,House ❑ Commercial ❑' Trailer Court ❑ Motel [] Other ❑ <br /> I Number of living units: __/---- Number of bedrooms --Number of baths ---L. Lot'size --------1,0_�...-..X_..... <br /> __�________.._________ <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 ❑ Clay ❑ Adobe [Hardpan E] 5 <br /> Previous Application Made: Yes ❑ No [ New Construction: Yes [e No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tankkor cesspool perm4ted if4ublic sewer is available within 200 feet.) <br /> Septic -n Distance from nearest well__a.3_p_.__Distanc from fpunda�tion__ e ---- <br /> ----/_.-_".. Materi�l_ <br /> 2 No'. of com artmen-ls_.I_-..t-"*�_.Size_ _ .x x �_.___Li }uid de th-------------------------- <br /> i <br /> -___-------___-. -_ <br /> P 9 I? P Y <br /> Dispos Field: Disfance from nearest we ._'S__0_____Distance from foundation______l_Q___ ---Distance to nearest lot line------ ____-- <br /> Number of lines:--.--------' --Length of each line__ _�_ .5�_.3,S�.Width of trench---------' ��-------------- <br /> Type of filter'material__eQ`e_ __________. epth of filter material___'__)_,-��-------Total length-_--_---___ -ZO-- -------------•.- <br /> _ j <br /> Seepage Pit: Distance to nearest,well_,I�-i.D.*'.`_��Dist�-nce'"from"foundation .____-.......Distance to nearesfi loft lineIR _ ___________ <br /> Number of pits------J-------------Lining material_0_�___R_i'Ft�i��j?ameter----*�- `........Depth------,�- ------- 5 , <br /> Cesspool: Distance from nearest well------ --------Distance from foundation------------.-------Liningmaterial____----..-----.----._--__--------_--. r <br /> ❑ Size:..tDian eter---------------------------- --------Depth----------------------------: -----------------Liquid Capacity----------------------------gals. W . <br /> Privy: Distance.from nearest well-.------------------------------------------------Distance from nearest building______-"-"_-_--_---_"--__-_--_-.--_._._. <br /> ❑ Distance-to nearest lot'line-- - <br /> ---------------------------------- --------------------------------•----------------------------------- <br /> Remodeling and/or repairing (describe):----------------------------------------------------------------------------•--•------------------•----------------------------------------------------- <br /> ----------7-------------------------- <br /> ---------------•-------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------I .. <br /> -----------------------------------------••-----------------------------•-------------•------------------------.-.------- -------------------------------------- <br /> ------------------------ ------------------•----------------------- -------------------------------------------------------------------------•-----------------------.------------------=-•------------------------_---------- <br /> I hereby-certify that I have prepared thisapplication-and-that the work will-be-done-in-accordance wifh San Joaquin County } <br /> ordinances, State laws; and rules and re'gulatio of the'San°Joaquin Local Health District. <br /> (Signed)-., -- _�- --------------------------------'--------------------- <br /> ----------------------------------------------------------.(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 /> s <br /> R FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------f- ----- ------------------------------- ---------•----•------------------------ DATE---- -r <br /> REVIEWEDBY------------------------------------=-- -------- - ------- ------------------- ------ DATE------ <br /> BUILDING PERMIT ISSUED------------• -- =------- - ----- -------------------------------------------------------------- DATE------------------------- <br /> --------------------------------------------------------------------------------------------------•-------•-•----------•-------------------•---------------- <br /> Alterations and/q;'�ecommendetions-4= - ` - ----- ---- <br /> -------------� � -A'. _� -1 'f�------ <br /> u� b ---- -------� - --- <br /> --------------------------- <br /> ----- ----- <br /> --------------.- <br /> ------------------------------------------ ------------------ ---- -------- ------- --------------------- .---------------------------------------------------- <br /> FINAL <br /> .- - - ---- <br /> FINAL . <br /> INSPECTION 'BY:-.-----qaj --------------------------------- <br /> Date �6 l� = <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 /> FS--9-2M ; Revised W-2100 <br />