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APPLICATION FOR SANITATION PERMIT Permit No. --F5...... <br /> (Complete in Duplicate) j - a� <br /> Date Issued �------ ----------- <br /> Applica{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 No. 549. # <br /> JOB ADDRESS AND LOCATION--------------------------Ar-l5------- ------------ <br /> f <br /> Owner's Name------------- --------=------------------ �s � 1. --------------- ----------- Phone--------------------- <br /> Address---------------------------------------------------- ----------- ----------.-.-------------------------------------------------------------------------------------------------------•------------------ <br /> Contractor's Name----- S1PP_,P7,-,-'-------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence 0 Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ----------------- ------------------------------------------ <br /> Water Supply: Public system` Community system ❑yPrivate ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑,r Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made::.` Yes ❑ NO Y New Construction: Yes No ❑ <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 /> ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------------------.--- <br /> Type of filter material------------------------- of filter material---.----------- ----- length__--.-.-.__-----.__-..-_---------_-----.-- <br /> F <br /> Seepage Pit: Distance to nearest-well----------------------Distance from foundation-------------------.Distance to nearest lot line_-----_.--.-___- \ <br /> ❑ Number of pits-------i--------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> Q� <br /> i <br /> Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material-------------------------------------- <br /> ❑ Size: Diameter---------------------------------- -Depth-------:------------- ---------------------- -----.Liquid Capacity----------------------------gals. . <br /> Privy,; Distance from nearest well------------- --------------9 ---- --:----Distance from nearest building---------------- _ --.-----_-----. <br /> Distance to nearest lot line------------------------- ---------- __ ---.--------- <br /> Remodeling and/or repairing [describe):------------------------------------------------------------------------------------------------ -------------------------------- <br /> ' ---------------•--•----•------•--------......----------------------------------------------•--------•------------------------------------------------------------------ ----------------------------------------------------- <br /> -----------------------------------------------------------•-------••---------------------------------------I..............I-------------­..­-------------------------------­--------------------------------- <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. F <br /> � t <br /> (Signed)--- ------ ,� ' `'•�-�> ----- 1 ( I <br /> 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 /> ' S <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------- ------------------ -- r'' DATE -' _&�_s- <br /> REVIEWED BY --- - --- ---------------------------------- DATE------------------------ <br /> --- --------------'-------------- ---- -- -------------------------- ------------------------------------------------------------ <br /> BUILDING PERMIT ISSUED-------------------------------------------------------------•---------------------------------------- DATE-----------'-------------------- <br /> ---------------------------- <br /> Alterations and/or recommendations: -------------------------------------- - ------------------------------------------------------------------------•-••----------------------- -.--- <br /> ----------•--'-----------------•--------------------•-----------------------------------•-------------------------•-------------------------•---------•--•---•--..----_._----•--.....---•----- <br /> r <br /> ---------------------------------------------------------------------- -------- -------------- •----------------------------------------------------•------------------------------------------------------------------- <br /> ' r <br /> FINAL INSPECTION BY:-'-' ------------------- ------ Date---'--d f <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-2100 <br />