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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued <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 County Ordinance No. 9. e <br /> JOB ADDRESS AND LOCATION--------- -------•�----- f /C ---------------------------•------------------------------------------ <br /> Owner's Name--------C��(�---r---- Phone. <br /> Address... 1.. - .......�r___P1' 'f� ------------------------•------------------------.....--.-----------------------------------------------•-------------------- <br /> Contractor's Name__..--.-•. -- _ ._. Phone.-- -ld� <br /> Installation will serve: Residence PqApartment douse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms ,' Number of baths .-l__ Lot size _.___�? ._!r_ �� _.______________________ <br /> Water Supply: Public system (�a_ Community system ❑ Private ❑ Depth to Water Table Ca ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No (B,•- New Construction: Yes 4_ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well _A/_e>-eL-Distance from foundation',ZA_............Material---CSC of fi_'_--__ __ <br /> ® No. of compartments------a-------------Size._% - -----X-86---Liquid dep_k_:E6Z__._---..-.Capacity._... !------- <br /> Disposal Field: Distance from nearest well ./.��P}istance from foundation---s�____--------Distance to nearest lot line—/0....... <br /> cd Number of lines___________ __ ____�,.______Length of each line_____ - /1 <br /> -p--------.�,---.width of trench --��-------------------- <br /> Type of filter material � 3_�Depth of filter material_-._. _9_ Total length____c _ __------_-__---_-_-_---.- <br /> Seepage Pit: Distance to nearest well... Distance from ffo�oun"daaation---_L U____ Distance to nearest lot line---�_4�_______ <br /> ZNumber of pits.-- -/--------------Lining materia_L _glee: Diameter_---- Depth.__,,-2' ----------------- v <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-----.------------- Lining material-------------------------------------- N <br /> 0 Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity---------_-----------------gals. �t <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-.--...-----_-------_---_---._-----_---. <br /> ❑ Distance to nearest lot line-------------------------------------------------------------------------------------- ------------------------------------------------------ <br /> Remodelingand/or repairing (describe)-------------------------------------- --------------------------•------------------------------------•-•----------••------------------------------------ <br /> •-•-----------------•-----------•-------------------•------------------------------------------------------------------------•------------------------•-•-------------------------------------•------------------------------- <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, St s, and ruled and regulations of the San Joaquin Local Health District. <br /> (Signed)--------------. / -- ----------------------•------------------- ---------------- --(OWner and/or Contractor) <br /> By;�_ fry -Q - -- s - --- •--- -----------------------------(Title)----------- --�---- ------------ - ------------- <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 /> APPLICATIONACCEPTED BY--------- - - -- ----- ----------- ---------------------------------------- DATE------- - ------------------------------- <br /> REVIEWEDBY---------------------------------- ---------- ---- ------------------------------------------------------ DATE--------------- -------------------------------- <br /> BUILDINGPERMIT ISSUED----------------------------- - --- --- -----------------------------------------------••-- DATE--------------_ _ <br /> Alterations and/or recommendations--------------- ------ --- --- --------•- -------- ----------------------------- <br /> Alterations <br /> - --------------- <br /> -•----------------------------- ---•----------------- ------ -- - ---------... --------------------- <br /> - --------- ----- <br /> --------------------------------- ---------------------0. ................ ---------------------- <br /> ---------- - <br /> 1 b ------ - - ------------------------ <br /> ---------- ---------------- Date--- ---- <br /> .I '_'_.�_�/'-_. •----------------•---- <br /> FINAL INSPECTION BY:.... _ _ _&------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9 145446 ATWOOO <br />