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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in D6plicate) <br /> Date Issued 3237,SY <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> -This application is.made incompliance 'With County Ordinance No. 549. <br /> ,1J"Ir I .. <br /> JOB ADDRESS AND LOC TION -------- JK <br /> K )------sux A---------------2�-------------------- ------/------------ ---------- <br /> ------------------------------------------------------------ <br /> Owner's Name-------------------- ---------- -- Phone 717 3 <br /> R e ----------- ---------------------------------- <br /> Address----------------------------------------------------------- ------- ------------------------------------------------------------------------------------- <br /> Contractor's Name----------- '11------------------ ------------------------------------- -------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence 2---'Apartment House 0 Commercial E] Trailer Court E] M�0el Other E] <br /> 3, ------------------------------------ <br /> Number of living units: J.____ Number of bedrooms q--- Number of baths j_____ Lot size ----------- - <br /> Water Supply: Public system E] Community system F-1 Private 0' Depth, to.Water Table If ' ft, <br /> Character of soil to a depth of 3 feet: Sand C] Gravel E] Sandy Loam P-,--Clly' Loam E] Clay E] Adobe E] Hardpan ❑ <br /> Previous Application Made Yes [] No ®1---New Construction: Yes Pf"'No M FHA/VA. Yes-F] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Xnk: Distant from nearest well_�R_f"�__Distance from foupdation--- -----------Material--- 64 ------------------ <br /> No. of,'compartments---- --------- ---Liquid clep�h----------�$ ------------Capacity---- <br /> Disposal Field: Disfance from neare'st weII_.t�__(-.._Disfance from foundation---1()-----------Distance to nearest lot Iine____S <br /> ---------- <br /> Number of lines-------?--- - -------------Length of'each line----' -1--------------Width of trench----Z-411............ ------- <br /> Type of filter material__Xl'_�-----------Depth of filter material------If-'!--------Total -length____._,!__Y-,,Z----------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line___--_-_--_.---. <br /> ❑ <br /> ine----------------- <br /> El Numbe"r of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundafion--- ...........-_.Lining material-------------------------------------- <br /> El Size: Diameter----------------------------------.---Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest wail__, 1___________7------------ --------------:----Disfance from nearest building--------------- <br /> -------------------------- <br /> ❑ Distaric'e to nearest.lot line----------------------------------------------------------------------- ---------------------------------------------------------------------- <br /> Remodeling and/of repairing (describe):------------------------------------------------------------------------------------------------------------------1.-------------------------I------------ <br /> -----------------------------­----------­ ------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- <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, an4 rules and regyjja+ioris of the San Joaquin Local Health District. <br /> (signed)-.4r:-----------------------------------e---- ------ -------------------------------------------------------------------------------(Owner and/or Contractor) <br /> ------------ <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 /> FOR-DEPARTMENT USE ONLY . . <br /> APPLICATIONACCEPTED BY___W_41),'�__ __----r- ----------------------------------------------------------------- DATE------ ----------------------------- <br /> REVIEWEDBY------------------i!--------------------------------------------------------------------------- ------- ---------------------------------------------------------- DATE----------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------- --•---------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recomrnenclations:----------------------------------------------------------------------------------------------- ---------------------------------------------------------------- <br /> II <br /> ---- ----- -------------------------------- ------- ------- -----------_1---- ------------------------------------- -------------------------------------------------------------- <br /> --- - --- --- --- <br /> _i-------- --------I --- -= <br /> -------------------------------------------------------------------------------------------------------------__----------------------- ------------------------- r��----------------------------------------------------- <br /> ---------------------------------I------------------------------------------------------------------------------------------------------------------------I------------------ ----------------------------------------- <br /> FINAL INSPECTION BY:------ ------------ -------—--------------------------------- Date--. --------------------------------- <br /> -7111f -7------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California :, Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised 1-57 F.PrCo. <br />