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I <br /> APPLICATION FOR SANITATION PERMIT Permit <br /> (Complete in Duplicate) <br /> Date issued A-1 -i <br /> Appli6-*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 No. 549. <br /> JOBADDRESS AND LOCATION-----------2.Q-H-Q--------� Ol c-----------------------------------••----------------------------- ...----------------------------------- <br /> Owner's Name-------------------------------------------- I�c---------�-����_-•------- -- ---- ----- ----------------------------------.-,7 Phone-----=---------------,-------------- <br /> Address. ±-------------------- RQ-------------- w= �1�-ti y •-1AF� <br /> Contractor's Name------- ---------------------- A---- -------------------------- -------------------------- ------------------ Phone------------------------------------ <br /> A Installation <br /> ---•-------------------• --------- <br /> *Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms .- -- Number of baths ____I_ Lot size ---- _ _'- - _ti--------_----------------- <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table _V-,ft. � <br /> Character of soil to a dep+h of 3 feet*1 Sand ❑ Gravel [:1Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ .No ❑ <br /> r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> .. <br /> Septic Tank: Distance from nearest well_________________Distance from foundation-------------------.Material-------.____._____.____________._________-_-_. <br /> No. of compartments-------------------------Size-----------------------•--------Liquid depth--------------------------Capacity----------------------- <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 french----------------------------------- <br /> Type of filter material------------------------- 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-----------------------Dept �1 <br /> Cesspool: Distance from nearest well____�-------Distance from foundation-------/1j_- ,___.Lining material__._.______�� ------- <br /> Size: Diameter---'------- ------------------------Depth. t------------- -----------------------------Liquid Capacity---------6U-Q--------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------- V► <br /> ❑ Distance to nearest lot line------ -- --------------------------------------.--------•------------------------------•--------------------------------------------------- <br /> 0 .Remodeling and/or repairing (describe);-------- ------------------------------------•--------------•-----------------------=----------•---------------`-------------------------------------- <br /> --------------- <br /> ----------------••-----------•-•--------- •------------- - <br /> =------------•-----------------------•------- <br /> I 1 _ <br /> --------------------------------------I----------------- 1 -----•-------------------•------•----------•-------•---------•----------•--••-------•----------------------- --- .-----.--------------------•--_--_--- <br /> I herebycertifyWa+ I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, tat 1 ws, and rules and reg ations of the San Joaquin Local Health District. <br /> { <br /> ----- --=-•---------- <br /> ___.(Owner and/or Contractor) <br /> (Signed)------ --- R'l ------ - --------- - -- - - ----------------------­-------- Ti+le <br /> SY= {(Title)--------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> y FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - L-T------------------------ DATE--- -------- r-- <br /> 4. = -= " ' <br /> REVIEWEDBY--------------------------------- -----------------------------------------------------------------------•-------------------- DATE------------ <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------•--------------------------------------------- DATE---------------- -- <br /> Alterationsand/or recommendations:----------------------------------------- -------•--------••--------•-••-----------• -------------••---•----------------•-------------------•------------------ <br /> ------------- -----------------•-----=------------------------------------- ----------------------------------------------------------------------------------------------------- ---------------------------------- <br /> ----- -------------•---------- •----•------------•--- i------------------------------------------------------------- <br /> --------•---••- •------ ----------------------------------------------- --------- <br /> FINALINSPECTION BY--------------V ' A-um------------•--•---- Date....`--------------- 1--------- ------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 .. <br />