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APPLICATION FOR SANITATION PERMIT Permit No. ....... <br /> (Complete in Duplicate)cafe) Date Issued <br /> A <br /> �plicar*ion is hereby made to the San Joaquin Local Health District for a permit to construct and instal[the work herein described. <br /> This <br /> application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS ANLOCATION_ -------- `-- 4--y <br /> - - -------------------------------------------------- <br /> it) A)�Ov 9 <br /> - ---------- -- - ------------- - <br /> Owner's Name------- <br /> -------- - --------------------------- ----------------------------- ---------- Phone--- <br /> Address------- --- ---------------- ------------ <br /> ---- ------ ------------------------------------- ---------------- <br /> x <br /> Contractor's Name__.---• ---Di4) ---------------------------------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence X Apartment House [] Commercial E] Trailer Court [] Motel P.,,,,Other El <br /> Number of living units: -.-/____ Number of bedrooms ---XNumber of baths __/__ Lot size ------- -------------- <br /> Water Supply: Public system A Community:system E] 'Private E] Depth to Water-Table <br /> Character of soil to a depth of 3 feet. Sand 0 Gravel E-] -Sandy Loam El Clay Loam El Clay El Adobe Hardpan E] <br /> Previous Application Made: Yes'E] No New Construction: Yes No F-1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> di ------------------- <br /> Septic Tank: Distance from nearest well_ 0-----Distance from founclafion—'/0---------M,teriai---R�w 4V O'd <br /> No. of compartments--------A.,------------Size_A1X__Y_X_1j0----Liquid depth----------9n'..__"'_.Capacity-.-�4 <br /> Disposal Field: Distance from nearest w�l----- -Distance from f-pundation-------%___1------Distance to nearest lot line.__1_61��. <br /> ANumber of lines----------------q._'I--------------Length of each Width of trench----- ---------------- <br /> Type of filter material._--- J_k----------Depth of filter material____._J.�............Total length----------- ----------------- <br /> Seepage Pit: Distance to nearest well-'"_4-------------------Distance from foundation..............:......Distance_ <br /> ......... ...Distance to nearest lot line----------------- <br /> El Number"of,,pits--------------- CiFn'inq material------r - --------------------Size-: Diameter-------- ----- -7--:----.Depth--------------------------- <br /> Cesspool-. Distance from nearest'well-----------------Distance from foundation--------- -----------Lining material_______..-__.-._--------________.___. <br /> ❑ <br /> aterial-------- -------- -------------------- <br /> El Size: Diameter------------------------- ----------- Depth---- ---------------------------------------;--Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------- -- ---- ---------------------------------Distance from nearest building____________________-.______________.___. i <br /> El Distance to nearest I& line---------------------------------- -------------------------------------------- --------------------------------------- <br /> Remodeling and/or repairing (describe}:-----•----------- ------------------------------------------------------------------------------------------------------z...------ == <br /> )K <br /> ----------------------------------------------------: <br /> ------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------- ------ ------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------- ------------------------- -------------------------------------------------------: -------------------------------- <br /> I hereby certify that Iork will be done in accordance with San Joaquin,C <br /> -have prepared this application and that the w 3or4� <br /> ordinances, State "I -, �aWrule sand rectulations of the San Joaquin Local Health District. <br /> (Signed)_- -- ------ - 0 ------------ ------------------------------------------------- .(OiWner and/or Contractor) <br /> By----- --------- -----------------------------------­­------------------------------------------------------------------------ -------------------- <br /> (Plot plan, showingsi of lot, location of system in relation to wells, 6 ildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT-USE ONLY <br /> APPLICATION ACCEPTED BY----------------- -------- -- ------ ------------------------ ---------- DATE------------- <br /> REVIEWED BY-------------------------- ------ ------ ------------------------------------------ too- L.-15 <br /> ------ -------------------------------- DATE----------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------•------------------------------------- ------------------ ------------------- ---------------- DATE----------------------------------------------------------- <br /> Alterations <br /> ATE------------------------------------------------------------Alterations and/or recommendations:-------------- ------- ----------------------------------------------7--------------m--------------------------------------------------------------------------- <br /> f. <br /> ----------------------------------------------------­------------------------------------------------------------------------------------ ------------ ----------------------------------I-------------------------------- <br /> ---------------------------------------------------------- ----------------------------=----------------------------------------f--=--------------I -------- --------------------------------------------------------- <br /> . - . . - - t;6I- :----------- <br /> -------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------I----------------------- <br /> -------------------------------- ------ -------------------------------- ------ - ------ ----------------------------------------------- ------------------------------------------------------------------------ <br /> FINAL INSPECTION BY:AWK� ---------------- "Date-...,,/ <br /> ------------------------------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Stre <br /> Stockton, California Lodi, California Manteca, California Tracy, Californi, <br /> ES-9-211 Revised W-2100 <br />