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R APPLICATION 'FOR SANITATION PERMIT Permit No. _____________________ <br /> (Complete in Duplicate) <br /> Date issued <br /> t <br /> Applical-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 Na. 549. <br /> 44 i <br /> JOB ADDRESS AND CATION--------------7_---------------- ----------•-=----------- ----------• ------------------------------------------ <br /> 30� r� <br /> OwnersName d-•-�`--------jPP ----------------------------­­----------- ---- --------- --------•------------ Phone- -___-------------------. ----- <br /> Address-__- ---------- ._.. - --- --------------------------- <br /> s':7�/� <br /> ------------------------------------------=•---------- ----------------- <br /> Contractor's Name-------------- Phone� � <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel L] Other ❑ <br /> Number of living units: _/__ Number of bedrooms a9-_ Number of baths Z--- Lot size -_Cam ______ �a____-----__-------- <br /> _____ <br /> Water Supply: Public`systern E__�Community system ❑ Private ❑ Depth to Water Table ft. "r <br /> r <br /> Character of soil to a depth,of 3 feet: Sand-E] Gravel-❑ --Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: 1Yes ❑ No �ew Construction: Yes ❑ No 0� t <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: I <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t <br /> S tic anh: , Distanceifrom nearest well-----------------Distance from foundation----------------------Material-----------------------,__-__---_______..______- <br /> c.( No. of compartments---------- ---------- ---Size----•-----------------=-----•---Liquid depth_---------T------------Capacity............=---------- <br /> Disp I P1g4d: Distancelfrom nearest well_________________Distance from foundation___-----------------Distance to nearest lot line____________-__•_ <br /> Number of lines------------------------ <br /> -----------Length of each line--------------------------------Width of trench----------}----------------------- <br /> Type of'filter material-------------------------Depth of filter material-----------------------Total length__`____________-.____________-.___.___. <br /> Seepage Distance to nearest well__/Distance from foundation_...+-r�d_- Distance to nearest lot line` ___._____ <br /> Number of pits------ ------------Lining mate rial___R_4-k_____Size: Diameter___ �------------Depth______ _"_---_______--_-- <br /> Cesspool: Distance from nearest welf-----------------Distance from foundation--------------------Lining material _-----______-.____.______;________- <br /> ❑ Size: Diameter------ E-------------------=--=----Depth----------"------!---,--,-- ---�----------t----1----Liquid Capacity----------------------------gals. G,n <br /> Privy: Distance from nearest :1-.-Distancewell________________________-_._______._______ from nearest building___________________________-_-_-_____._. <br /> ❑ Distance to nearest lot __.__"^_"_: ----_. --------•-----•-•---•--•--=•----- <br /> --------------------------•-•-------------- ------- ------------- <br /> 6�Remodeling and/or repairing (describe):_"-- ---"-_-- - ------ --__ -___ -- --- <br /> -------------- = ----•--------------------------------------------------------_------ - ; <br /> -=----------•--------------------------------------- <br /> t i ' <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, Sta a aws,an ules and regula ions of the San Joaquin Local Health District.. <br /> I t <br /> (Signed)-------- -------------------------------------- ------------- ------(Ownerand/or Contractor) <br /> 10 <br /> By:.......- - <br /> ----- -- - <br /> -- -- `-------(Title) ---------- ------------ <br /> (Plot plan, showing size of lot, location of sys+e,tl(in relation to wells, buildings,,etc., can be placed on reverse side). <br /> � s <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY�*---------------------------- --- - - -- ----- ---------------------------------------- DATE__,__---------":.�:--'=-`-------------------------------------------------- <br /> REVIEWED BY --- `----- -- ------------------------------------------------------ •---- DATE = <br /> BUILDINGPERMIT ISSUED--------- ----------------------------------- -------------------------•--------------- DATE------- ---------------------------------------------- <br /> Alterationsand/or recommendations:----=----------------------------------------- --"--"-""----------------------------------=--------•--------------------------------------------•------------- <br /> L. <br /> -----•----•-----------•----------------•------"----"-"-•------------------------------------------------------------------ --•-------------------•---------------------------------------- <br /> ---------- --------------------------------------------------------.------------------------_--------------..--------------------------------------•------------------------------•---------------------------------------- <br /> -- <br /> FINAL INSPECTION BY:_-----� -- -- ------------------------------ _ .. , Date----- ---- -----'---rl�- --------�5------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Stroot 300 West oak Street 132 Sycamore Street 614 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />