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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Data Issued . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to nstruc and install the work herein described. <br /> This application is made in compliance with County Ordinance No�. 549 <br /> JOB ADDRESS AND .� <br /> ,LQCATION . --- - ----- ------ - -------- ---------------------------------------------------------- <br /> Owner's ame__",--- ------- <br /> --- -------------------- ------------------ ---------- Phone.--.,4/---- <br /> Address.... .. --------------------------------------------------------------------------------------------------------------------------------- <br /> 4e.:K_1-------------------------------- <br /> Contractor's Name______.____ - ------------------ Phone_ _,_.7 <br /> Installation will serve: Resid��nce Apartment House Ej Commercial El Trailer Court E] Motel,[] Other E] <br /> Number of living units: --- Number of bedrooms----'L, Number of baths Lot size -------- ---- <br /> Water Supply: Public system 11 C Community system El Privat 0 Depth to Wafer Table � <br /> of -__ ft.Character of soil to a depth Meet: Sand E] Gravel ElSandy Loam ElClay Loam [] Clay Aclob ' Hardpan E] <br /> Previous Application Made: Yes E] N New Construction: Yes 0 No r <br /> 4 ?X <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available'within 200 feet.) <br /> Septic 7Ta nk- Distance from nearest well_________________Distance from foundation--------------------Materiai------------------------------------------------ <br /> �1>V11N.;.of c4mpartments------ -- <br /> - ----------.-----Size-----•------------- --.,---,---Liquid depth-------------------------Capacity--------•---- --- <br /> ------ - <br /> /- P i <br /> D1111111 posal Field: Distance from.nearest well---r?d-------Distance from foundation-- Distance to nearest lot line <br /> I7�--------------- <br /> r 6f lines_ -----Width of french— -------------------- <br /> lines_'____. �_i - <br /> _AzP'�_ - --------Depth of filter maferiaI___'/* -- ----------------------- <br /> Numb L7------ -------Length of each line_________- -- - - <br /> Type of filter 'material-,7 length---------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line__.____.__.______ <br /> i'__________" - W <br /> F-1 Number Of pits---------_-___-_----Lining material : ------ Size: Diameter-_:---------.------ Depth-------------------------------- <br /> 11 ' - I __Q11 <br /> Cesspool: Distance from nearest well-----------------Distance from foundation_...____-__:- Lining. material----------------------------- ------- <br /> ❑ <br /> Size: Diameter------------------- ----------------Dept h------------------------- --------------------------Liquid Capacity- .-------------------------gals. <br /> Privy: Distance from nearest _______________Distance from nearest,bu0cling-- ------------------ ------- <br /> ------------ <br /> Disirn&e to nearest lot-line---------------------_`7­7--`�---------­-------------------------------------------------- <br /> iji(clescribe): ------ ------ ----------------------------- (A <br /> Remodeling and/or �epa�ring <br /> -------------------­---------­---------------- -------------------------------------------------------------------------------------------I-------- -----------------------------------------------------------I--------- <br /> ---------------------- -------------------------­-Il------------------------------------ ----------------7---------------------------------------------------------------------------------------------------------------- <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, Sfafe)aws) and r s d regulations of the San Joaquin Local Health District. <br /> (Signed) vo, <br /> --------_i ----------------------- ---------------------------------------- --- -------------------------------------------------------(ON;ner and/or Contractor) <br /> J'A <br /> By:----------------------- ....... <br /> 2.. /1 1 ---------- ---------------------------------------------(Tif I e) -------- <br /> I ------------------------------ <br /> (Plot plan, showing.siz� 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 ---------- DATE_ --------------------- <br /> REVIEWED BY_.. 11...........------ <br /> 2----------------------------- --------------- DATE--- /. ---------------;Zk-—--------- <br /> ----- --------------- <br /> BUILDING PERMIT ISSUED--A--------- ----------------------------------------------- ------•-- ---••------------------------ DATE-----/ --------------------------------------------- <br /> Alterations and/or recommenlafions:---------------------------- --------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------I------------------------- <br /> ---------- -------------------------------------- ---------------------------------- - ------------------------------------------------------------------------------ --------------------------------------------- ------- <br /> ----------- ----------------------------------------------------------------------------- ---------------------------------------------------- -------------------------------------------- ----------------------- <br /> ------------------ --------- -----------------------------------------•-------•--------------------------------- ---------------------------------------------------------------------------------------------------- -------- <br /> 7 <br /> FINAL INSPECTION BY:-- <br /> -------------------------- --------- <br /> ry <br /> ... ........................ Date---- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-21v1 10-52 Revised W-2100 <br />