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• APPLICATION FOR SANITATION PERMIT Per it No ------ -_-- <br /> (Comple+e in Duplicate) Date Issued _L <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 Count Ordinan 549. <br /> JOB ADDRESS "LOCAFION _ • �� --------- ------- --- -------------------------------------- <br /> ((�Owner's Name----- • d Com_. ]'hone e �s � 7 <br /> Address--------------------------------------------------------- -------- ---- c <br /> Contractor's Name---------------------- ------ ' n _ Phone----_l---- <br /> . � - <br /> -, <br /> Installation will serve: Resides ce ❑ Apartment House ❑ Commercial ❑ Trailer �Court ❑ Motel ❑ OtherxC,o' <br /> Number of living units: -------- Number of bedrooms ________ Number of baths ------ Lot size -___________________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table�,42_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay cam ❑ Clay ❑ Adobe,k Hardpan ❑ c <br /> Previous Application Made: Yes ❑ No _New Construction: Yes ❑ No ❑ "�"�' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: SIN <br /> I o septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> STan�k�: Jnr - _Distance from nearest well_________________Distance from foundation--------------------Material____________________--_______.______________.. <br /> No. of compartments----------- -------------Size---_-----------__-___----------_Li Liquid depth -Capacity <br /> rsposal 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----------- Depth of filter material________ __ Total length_____________________________________— , <br /> Seepage Pit: Distance to nearest well---- fou dation__ _____.Distan a to nearest lot line---U1__._____ <br /> 5Z Number of pits------/-------------Lining materialn� -Size: Diameter---- ""-- <br /> Cesspool: Distance Distance from nearest well-----------------Distance from foundation--------------------Lining material____________________________________-. <br /> ❑ Size: Diameter------- ------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------------------------------------------------- from nearest building--------- .________-_____---____________. <br /> ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------- -------------------- <br /> Remodeling and/or repairing (describe):------------------- ---------------------------------------------------------------------------------- ------------------------------------------------- <br /> ----------------------------------------------------------------------•--------------•-------------------------•-----------•------------------------------- ----------------------------•-------------------------------- <br /> I hereby certify that I have prepared this application andt t # work will be done in accordance with San Joaquin County <br /> ordinances, State laws,a d" les and regulations of t e San Joa uin Local HeaIfh_ *+rice°. <br /> a / <br /> (Signed) -A ���� ----14------ ���5 C'� { wrr�fnr Contractor) <br /> y:------------------ --- -,r---------- ----- ------- ------------------------------------------------------------ <br /> ---------- ------------------------------------(Title)- -J •�' <br /> {Plot ]an, sh ze of lot, location of syst ren relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_----- -------_ _. --------- --- DATE----(r- <br /> _Y <br /> �' � - <br /> - - ----------------- <br /> REVIEWEDBY---------------------------------------------------------------------------------------------------------------------- DATE---- 4--------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------- --------------------------------------- DATE---------------- -------------------------------------------- <br /> Alterations and/or recommendations--------------- ----------------------- - - --- ---------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------ ------------------------------------ ------ ------- ----------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------- -------------- -----------------------------------------------------------_­1- ------ ------ ------------- - ----------- ---r---------------------------------- <br /> FINAL INSPECTION BY:--------------y--I'4 -- ------------ --------- Date--------- V <br /> -------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTR[CT <br /> 130 Soufh 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-2100 <br /> r _ <br />