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APPLICATION FOR SANITATION PERMIT Permit No. ....... ............ <br /> (Complete in Duplicate) <br /> Date Issued ____����.-- <br /> Applica+io is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This applica 'on is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCA ION..' `�Z --�-�-----------------�-----_ - 1 <br /> Owner's Name-------•------ � T Phone f ,.. <br /> Address_ � d'�t� -------------------------------- <br /> ••---•--•-----------------•-------------- ry �. <br /> c' , <br /> Contractor's Name_-.-__.---_" - `� { + <br /> 4 ..,� � I <br /> Installation will serve: M Residence Apartment House Commercial Trailer Court Motel Other El <br /> Number of living units ______ Number of bedrooms Number of baths .1----- Lot size -------- _- --------'-----'------------------------ <br /> Water Supply: Public system ❑ Commmun ty syst m [Ir Private Depth to Water Table ��-�ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobe�Hardpan ❑ <br /> Previous Application`Made: Yes 27afNo ❑ r, New Construction: Yes ❑ No E <br /> TYPE OF INSTALLATION`ANDiSPEC IFICATIONS: <br /> (No septic'`tank or cesspool ipermitted-if public sewer is available within 200 feet.) <br /> p Tank: Distance from nearest;well___S C_-.-..__Distanceffrorriilfoundation--.-_�V------ <br /> iaeras-__ f'��-' - _ <br /> 5e.tic <br /> . <br /> - <br /> � of compmen#s-----------� ----$ize---'-1�-�---�x-�------Liquid depth---------�------------Capacity...... -------------- <br /> No. ��Dis <br /> .__Distance from'foundation__._.�U _Distance to nearest lot line______.____. <br /> ,p al�"Field: Distence.f.rom Weare t,well-,-�c`�._ ----.-- <br /> ✓`'��] Number�of lines___.__'�_Y___ ._�.•�[_____________Length of each line________ ' _ __.._ _ ....Width of french.......____�=____ ___ .--------- <br /> Ty <br /> ________ �•) <br /> Type of filttrrr a terial.J _!�'?�-_-Depth of filter material-�_. _ g 1" <br /> � h ------Total length /�Q-� •--------.. <br /> {l - <br /> Seepage Pit: Distance to riearest well----------------------!Distance from foundation___::__":_________,Distance to nearest lot line----------------- <br /> ❑ Number of pigs----------------------Lining material----------------------_Size: Diameter-----------------------Depth--------------------------------- <br /> i <br /> Cesspool: .r- <br /> Distance from nearest well-----------------Distance from foundation--------------r...- Lining material-_---------------------------------- <br /> Si <br /> -__.-_ -_ <br /> 14 <br /> ❑ Size: Diameter-------- -------Depth------------------------------------------- ----Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-----------------------------------------------_Distance from nearest building <br /> ❑ - Distance to nearest lot line------------------------------------------------•----•----------------- ---------------------------------------------------------------------- <br /> T <br /> 'Remodeling and/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, State laws,'=and rules and regulations of the San Joaquin Local Health District. <br /> (Signs d)---- ------------------------ ----------- - ---- -- - -- --- --- -------------- ------------------------------- -------------------------------------(Owner and/or Contractor) <br /> By: {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 /> APPLICATION ACCEPTED BY------------- - ---- ----------------------------------------------------------- DATE f <br /> 1/;�f- <br /> REVIEWED -BY-- = ------------------ --------------- ---------------- -------------- -------------------- DATE---------•- - -= y---------------- <br /> BUILDING PERMIT ISSUED ---- -------I---------------------------- - DATE. <br /> - ---------- <br /> Alterations and/or recommendations: =-------------------- -. --------- <br /> ----------- -------------------------- -----------•--------------------------------------- ------------------------------------------------•-------- ---•- - <br /> ------ <br /> -------------------------I--------------- ----------------------- --------------------------•------•------------------ --.._..-------------------------------•---•-••-•------------ <br /> ----------..»--------------------------i-'-'-•----------------_..__.-._..-------------.....--'----------------------•-•-------------------------------.---------- <br /> i <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> FINAL INSPECTION ABY:_.._....:.. ��_ .d°'f/ ........-- -- -_...Date--- ��. -- <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-21001 <br />