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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued <br /> Applica4ion is hereby made �o the San Joaquin Local Health District for a permit to construct and install the work herein clesciribed. <br /> This application is made,in compliance with County Ordinance No 549. <br /> I A, <br /> JOB ADDRESS AND LOCA'TIQN--••-- _ ___ € k # <br /> ., -•- -----f7 �-----71... . ..............I------------------------------------------------------------------------------- <br /> . -1........ ----- --------- .. 1. ------------------------I....: - <br /> Owner's Name-----------" --------------- -- ----------- Phone--------------------------A---------- <br /> Address--------------------­E- ------ <br /> -- ---------- --- -- ----------------------------------------- ---------------------------------- -------- <br /> ---- <br /> Name,_ 6D4------- ------ --------------------------------------------------- --- -------- P1 Z4__-_f <br /> Installation will serve: Residence El""Xpartmerif House E] Commercial [] Trailer Court E] Motel L] Other E] <br /> N mber of bedrooms Number of baths __/--- Lot size e-------------------------------- <br /> Number of living- units: _._f--- <br /> Vater'Suipply: Public system' tem ❑ Private F, Depth to Water <br /> r <br /> i Community sys Table ft. <br /> Character of soil to a depthlof 3 feet: Sand E] Gravel [-] Sandy Loam ] Clay Loam E] Clay ❑ Adobe 2--'Hardpan ❑ <br /> :L <br /> Previous Application Made: ;X es E] No 9- New Construction: Yes El No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> sewer is available(No septic tank <br /> A or cesspool permitted if public sew 4ailable wifhin'200 feet.) <br /> Septic �Tlnk; Distance from nearest well-----------------Distance from foundation-------_----------Material------------------------------------------------- <br /> F-1. No. of compartmenfs--------------------------Size--------------------------------Liquid depth---------------------------Capacity----------------------- <br /> Disposal Field: Distance nearest well_________________Distance from foundation--------------------Distance to nearest lot line______.-________ <br /> Number of fir'les L <br /> -----------•-----------------------Length of each line----------.------_-----------.Width of trench----------------------------------- �j <br /> Type of filter material-------------------------Depth of filter material-----------------------Total length___________..:__._______-------- <br /> - -1 t . - 14 .., A <br /> e I e r T U a ...........I...... itante to nearest 0- 40------- <br /> Seepag' 'Pit-' Disfance;lfo nearest well-------—-------Disfanc fro fou d fion,_" TO bit lot lin <br /> Nurnber%'f pits-. .----- -----------Lining material-4.0-I& -- ---Size: Diameter____ -------------------- <br /> Cesspool: Distance from�nearest_well------ ---------Distance from foundation________________.__.Lining material-_--_---___________.________`_.______. <br /> ---------- <br /> F-1 Size: Diameter--------------------------------------Depth--------------------------------------- --;----------Liquid Capacity----------------------------gals. <br /> 4 <br /> Privy:- "_ - I <br /> __.Disfanc,"�,,,� nearest well-------------- --------------------------------.-Distance from nedreJ_building__1-------------------------------------- <br /> ❑ Distance.�ta nearest lot line------'- - - .6. - — . , — <br /> ---------------------------------------------------------------------------------------------- --------------------------------- <br /> Remodeling and/or repairing (describe):-------------- ---------------------------------------------------------------------------------I------------------------------- ------------------- <br /> - <br /> -------------------- <br /> ---------- ----------------------------------------------------------------------------------------------------------------- ------------------------------------------------- <br /> --------------------------------------- .......---------- <br /> ---------­ <br /> -­-------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------- ----------­---­-----------I----------------------------- -------------------7-------------------------------------- <br /> 1-hereby certify that 11 have prepared this application and that the work will be done in accordance with San-Joaquin-County <br /> ordinances. Sfa�afe�11 15 and- ,r,"ules and-regulations of fhe'San Joaquin Local Health District. <br /> .......... ........ ------------------------------------------------------------- ---------- 1;------- r a�d or Contractor-) <br /> (Signed - ----------- ----- - ------------la!vll_(7 <br /> y:- -------- <br /> --------------------------------------------------------------------------------------__----------------(Title)----- ---------------------------- ----------- <br /> (Pld+ plan, showing size of lot, locafion'o�f system in relation to wells, buildings, efc., can be placed on rever'se side). <br /> 11 FOR DEPARTMENT USE ONLY Aj <br /> APPLICATION ACCEPTED BY---:--------- -: - ------ --------------------------- ----------------- DATE------------- <br /> REVIEWEDBY--------I--------I----------------------------------- ------- ------------------------- -- ----------- DATE--------------- ----------- <br /> 1�------- ..... --------------------- <br /> BUILDING PERMIT ISSUED--' --- ----=--------=-------------------- --------------------- DATE--------------------------------------- <br /> Alterations and/or recommendations---------------------------------- ------- ------------------------------------------------------------------- -------------------------------------------------- <br /> --------------------------------------------------------------------------- -----------------------------------------------------------------------------:-------------------------------------­­-------------------------- <br /> ----------:1-------------------i------------------11----------------------- -----------------------------------------------------r---------------------------------- ----_--------------- ------------------------------- <br /> ...........-------­---------- <br /> --------------------- -------------------------------------------------------- --------­-I--------------------------------------------------:--------------- -------------------------------- <br /> ------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- ----------------------------------------------- <br /> ------------- ----------------------------------------------- <br /> FINAL INSPECTION BY.... Date__.-._.- -- ------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street II 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Sfockfon, California Lodi, California Manteca, California Tracy, California <br /> ni <br /> ES-9-2M Revised W-2100 <br /> 1i <br />