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APPLICATION FOR SANITATION PERMIT Permit No- -_- --------------- <br /> (Complete <br /> --_` <br /> (Complete in Duplicate) <br /> • � � Date Issued <br /> Application 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. 549_ <br /> JOB ADDRESS AND LDATION---------1-"-Z---•--•-----�_ S--`-------q7`-- e _I_ -------- i --------•--•------------ <br /> Owner's Name--------------- _ - �t-------11011-- 1 -------------------- -------------------------------------------- Phone-----------•------------------------ <br /> Address----------------------- - ---- - --------- --•-------------------------------------------------------------------------------- <br /> Contractor's Name------_-- •; --- `'4- dlt------------ ------------------------------------------- Phone---4-�... - 0 ------ <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units:"-/---- Number of bedrooms __Number of baths _I-____ Lot size Q _-�_ `G----------------------------- <br /> Water Supply: Public system! 9 Community system '❑ Private ❑ Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ ' Adobe Hardpan ❑ Q <br /> Previous.Application Made: Yes ❑ No [x New Construction: Yes ❑ No <br /> I <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_________________Distance from foundation--------------------Material___________________________________________-_ + <br /> ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well-----------------.Distance from foundation--------------------Distance to .nearest lot line----___-_________ <br /> E� Number of lines-----------------------------------Length of each line------------------------------Width of french------------------------------------ <br /> Type of filter material------------------------- of filter material-----------------------Total length____________________________,___-----._._ ` + <br /> Distance from foundation__ /__ <br /> Seepage Pit: Distabncce to nearest well-_ VIN _- t --------Distance to nearest lot line-.Ie --_- i <br /> f pits--&--I .,------- material:__ tClk:Size. Diameter_-___, _��____.Depth_ "___-_-_________-._ <br /> 1 <br /> Cesspool: Distance ::from nearest well_________________Distance from foundation--------------------Lining material____________--.---_-_________________ <br /> 0 Size: Diameter---------------------------------- --Depth-------------------------------------Y---------------Liquid Capacity----------------------------gals, <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__--__-_--.---_______________--________- <br /> ❑ Distance to nearest lot line--- --------------------------=--------------------- -------------------------------------------------------------------•-------------------- <br /> �`h ----- ---•--f-- ••---A------- --•-'-- <br /> -------•--------- <br /> C`4 <br /> `Remodeling and/or repairing (describe):----- <br /> -------- <br /> - --- ------• ------ ----------------•------- - --- - <br /> --------------------------------------------------------------------------------------------------------------­_­-------------------------------------------/---------------------------------—--------- <br /> -----------------------------------------------------------------------------------------------------------------------•--------------------•--•---------------------------------------------------------------------------- <br /> " I hereby certify that 1 have prepared this application and that the work will.be done in accordance with San Joaquin County <br /> t Local Health District. <br />` ordinances, State Paws, an Iles d re Mations of=the �n Joaquin <br /> 4=1 <br /> 9 q <br /> - ----------------- <br /> ----- <br /> _- � - ------------(Ownera...n o---------------------r Co ractor)(Signed) i <br /> By:--------------------- 1------------------------------ ----------------------(Titke} r <br /> n size of lot location of system in relation to wells,'buildings,s, etc., can be pla e on reverse side). <br /> (Plot plan, showing y 9 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY- -------------------------------------------------- ---------------------------------------- DATE_3 ------------------------------------------------- <br /> REVIEWEDBY----------------------------- - ---------------------------------------------------------------------------- DATE__,__!i:! ---------------------------------------------- <br /> BUILDING PERMIT ISSUED_------------- <br /> ---------------------------------------•--------------------------=------------ DATE-------- <br /> ---------------- <br /> Alterationsand/or recommendai•ions------------------------------------------------------------------------------------------------------ -------------------------------------------------------- <br /> .i <br /> --------------------------------------------------------------------------------------------- ------------------------------------- ---- --------- ----------------------------------------------- ---- - --- <br /> -------------------- <br /> FINAL INSPECTION BY:- --------------------- Date--------- Z� <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 8-51 Revised W-2)00 �C <br />