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APPLICATION FOR SANITATION PERMIT -Permit No. _'.` -7_.. <br /> (Complete in Duplicate) 7��' s C <br /> N' iJ Date Issued -------- <br /> _____ _.__� <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 ADDRESSNDCATI <br /> "/ ' 2. '. <br /> Owner's Name0O4 <br /> ---- --------•-----------------------------------------------—- --------------- Phone = <br /> Address---- Q .3 <br /> Contractor's Name---11---- -- ----•--------------------•---------------------- --------------------------------------------------- <br /> -----•---------------------- •-- -•---- Phone................................... <br /> Installation will serve: Residence Apartment House [:] Commercial E] Trailer Court ❑ Motel ❑ Other E] <br /> Number of living units: I--- Number of bedrooms2 Number of baths /------ Lot size _!v u k / Z <br /> Water Supply: Public system a Community system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam E] Clay E] Adobe Hardpan 11Previous Application Made: Yes ❑ No New Construction: Yes No ❑ FHA/VA: Yes ❑ No ell-,^ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> S tic ank: Distance from nearest well-----------------Distance from,foundation....)-e-------- <br /> Material_--- --_--- �f ---%! ---- <br /> No. of compartments__ _____ . __Size __•} ,___Liquid depth___ __ _ <br /> -------- Capacity �'r----�-----G% <br /> Disposal Field: 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 Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_________________ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material-_----________---__-_______-______. <br /> ❑ Size: Diameter--------- ---- ---- -- __ Depth--_------------------------------------------------Liquid Capacity-- -__ ----- _-_gals. <br /> Privy: Distance frpm nearest well---'*----------_ _ ________ ____ _____ _Distance from nearest building------------------------------------------- <br /> F-1 <br /> ________ -_ _________- ______-__- <br /> ❑ Distance to nearest lot line------------------------------------------------------ ------------------------------------------------ <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, State laws, and rules and-regulations of the San Joaquin Local Health District. . <br /> (Si ned k <br /> 9 )--------------�%vim/`----a`---i-`-- --------------------------- -----------------------------------------------------------------------------------(Owner and/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 on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------------- ------ ------------------------------------------------- DATE_------------- --- ---------- <br /> ----------- <br /> REVIEWED BY------------------------------------------------------- ---- ------------------------------------------------ DATE----- •- --- <br /> APPLICATION <br /> PERMITISSUED--------------------_----- ---- ------ ----------------------- ------ DATE- •-- -•---- ------ ------------- <br /> Alterations and/or recommendations: -------------------------------------------------------------- -----•---------------------------------- ----------- <br /> ------------ ----------------------- ------------------------ ------------------- - ---------------------------------- ................... <br /> _-- <br /> -.: <br /> -------------- <br /> --------------- <br /> -- <br /> . __rte__ ,.- -- -------------- <br /> --- <br /> ----- ---- --- - -------------------------------- <br /> LA <br /> ------ <br /> FINAL INSPECTION BY-------- ------ ----- �- Date----- - �---:----- •----- <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 1.57 F-P.CO. <br />