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_4 ------------ <br /> ilk APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued OR/ <br /> Application I i� <br /> plication is reby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This <br /> application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION---------- w.------------- ---------------------------------------- <br /> Owner's Name------------------------ ------------------- ...... ------------------------------- ----- Phone.-------------- ------------- -- <br /> Address............... --------------•-----.------------------ /------- -------------------------------------------------------- <br /> Contractor's Name-----------__------------------------ ------ C----------------------------------------------------- Phone--------9=�F&o7------ <br /> Installation will serve: Residence bK Apartment House [] Commercial [] Trailer Court E] Motel E] Other E] <br /> Number of living units: __/--- Number o of bedrooms -1--Number of baths .-/--- Lot size ---- ------- <br /> ---------- <br /> Wafer Supply: Public system 9 Community system El Private n Depth to Wafer Table �� ft. <br /> Character of soil to a depth of 3 feet: Sand ] Gravel [j Sandy Loam 0 Clay Loam [I Clay F1 Adob tK Hardpan ❑ <br /> Previous Application Made. Yes E] No D? New Construction: Yes 0 No <br /> 1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 1 ,4 <br /> o septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Distance from nearest well_________________Distance from foundation--------------------Material--------------------------------------------- <br /> ,6-1 No. of compartments--------------------------Size------- , Liquid clepth---------------- ---------Capacity----------------------- <br /> ------------------------ <br /> -11:t Distance from nearest well,................Distance from foundation--------------------Distance to nearest ]of line----------------- <br /> Number of lines---------------------------------._Length <br /> of each line------------------------------Width of trench----------------------------------- <br /> Type <br /> rench- ------- ------------------------ <br /> Type of filter material_______ <br /> ________________Depth of Cfer material-----------------------Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well__ ---Distance from foundation___1---------------Distance to nearest lot <br /> Z.- <br /> Number of pits------I--------------Lining mat eria I-C-C.b V_tC�,Size: Diameter._ 3__611____ _Depth_ <br /> W ­------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material._.._______________________________ <br /> ❑ <br /> aterial._.---------------------------------- <br /> 171 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well___ _______________--------------Distance from nearest building----.---_____________________-_ <br /> 11 Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- • <br /> - <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------ <br /> ---------------------------------- ----------------------­------I------------------------------------------------------------------------------------------------------------------------------------------------------- <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, <br /> 'f"aa laws,t and ryll and regulations of the San Joaquin Local Health District. <br /> I Contractor) <br /> (Signed)------ ---- ----; _ -------- --------------- - - ---- - ------ -- --- ------------------------------------------------------------ <br /> By:------------------------------................------------------ ----- -_- -,:- - -_-_ - --- -----------------tTitle)---- --------------- <br /> (Plot plan, showing size of lot, location of system jr�elafion to wells, b�b lllng,, etc., can be placed on reverse side). <br /> F611 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------ --- ------ ---------------------------------------- DATE------ -- --------- <br /> . ............. <br /> REVIEWEDBY---------------------- -- ------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED.-_.------------------------------------------------------------------------------------------------ DATE------------------------------------------------------ <br /> Alterations and/or recommendations--------------------------- ------ - ---- ----- ------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------I------------------------------------------------------------I--------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------•--------------------.--- <br /> ------------- <br /> -------------------------------- <br /> ---------------------- --------- ------------- ---- ----------- -------- ----------------0-------- -------- -------------------------------- <br /> 2----------------------------------------------------------- <br /> FINAL INSPECTION BY:--------------- ` - =l�(—--------------------- Date........... <br /> ---------- <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 10-52 Revised W-2100 <br />