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APPLICATION FOR SANITATION PERMIT Permit No. .. ..1...... ...... <br /> (Complete in Duplicate) , Q�J <br /> Date Issued ._�i __ <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 <br /> //County Ordinance No. 549. <br /> JOB ADDRESS AND OCATION Wit'-?-------- /�--- e ------------------------------------------------------------------------------------ <br /> Owner's Name--------1_��--•---- -----�ll_L__r-C.�---------------------------------------- -------------------------- __ Phone.................................... <br /> Address-------- `J�---------- ---------,-o-------------------------------------------------------------------------------------------------•----------------------------•--- <br /> Contractor's Name L/.!:. Pa.,/q4 <br /> 1 % .'"r-_----------------- - Phone a - ----�-------—7 <br /> Installation will serve: Residence [Apartment House E] Commercial E] Trailer Court F] Motel ❑ Other ❑ <br /> Number of living units: __/___- Number of bedrooms _. Number of baths -------- Lot size --____ -X_JGd__....._.._............... <br /> Water Supply: Public system [X 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 A Hardpan ❑ <br /> Previous Application Made: Yes ❑ No [4 New Construction: Yes [I No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Ta nce m nearest well_________________Distance from foundation--------------------Material___--_-____--_._-_-__-.-----.----_-_.-_-_____---. <br /> ® No. of ompartments---------- ---------------Size-------------------------------Liquid depth------------------------Capacity------------ --------- <br /> Disposal Fie f e ror` earest well_________________Distance from foundation..------------------Distance to nearest lot line-___.___-___---_ <br /> ❑ Number of�nes Length of ea Width of trench <br /> Type of filter material_________________________Depth of filter ial___...__:_ __..._____-Total length-______________-__-_________---------•--,_ <br /> Seepage Pit: Distance to nearest well----'-' _Dist e fromundation_ _. _ _?.'--..Distance Q. Distance to nearest lot line.....21 .._... <br /> [ Number of its._.__.__ _____..___Linin m eriaL..G©G __ ._ .4e iameter____3 ��_ <br /> P g --------Depth-----a2S---................ <br /> Cesspool: Distance from nearest well-________________ istance fro ation-------.------------Lining material------------------------------------- <br /> . <br /> ❑ Size: Diameter--------------------------------------Dept -------------------------------------- -------------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):--------------- -=---- -------------------------------------------------------------------------------------------------------•---------------------•- �V <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ..................................... <br /> ----------------------------------------------------------------------------------------------------------------------------------•-----------------------------------------------------•--•---------------------------------- <br /> I hereby certify that 1 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 /> (Signed)---------- 4J3./�ti`' ,-------- i__2_�.- -.-c-- (Owner and/or Contractor) <br /> ------------------------ <br /> By:._ ,- ----- (f 4._e e: C.2� -------------------------------------------(Title)-------- ----------------------------------------- <br /> (Plot plan, s-Fiowing 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 /> REVIEWEDBY ,i?-,. �`----------------------------------------- ------------------------------------- DATE b(- .................................------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ fi--------------............---•--.. <br /> Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------- ------------------------- --------------------- --------------- -----------------------------------------------------------------...........................--•-•---- <br /> ......I-----------------------------------------------------------•------------- ------------------------------------------------------ ---------------------------------•----------------------------------------------- <br /> -----------------­--­-----------------------------•---------------------------------------------------------------------------------------- ------------------------------------------••------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:.-.=_��---------------------------- Date--- -------? --S'-�---------_•-------------------- <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 />