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APPLICATION FOR SANITATION PERMIT Permit No. --------- <br /> [Complete in Duplicate)rIF-" t —S <br /> -- <br /> Date Issued -�----�----_----- r <br /> Applical-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. F_ "t . <br /> JOB ADDRESS AND LOCATION-----------A- -'i------ = <br /> OwnersName---------------••---------- �k'�1G�--------- ---------14 -- ---- ------------------------------ Phon c_ _ '�$ <br /> Addresss_,—=----------------- ---------------------------------- ---------------------------------------....----------------------------------------------- --•-------------------••----...-------------------- <br /> ContractorsName---------------------------------------- ------------- -------------------•------------------------------------ Phone----------------------------------- <br /> Installation will serve: Residence" Apartment House ❑ Commercial E] TraVer Court ElMotel El Other ❑ <br /> {-Number of living units: -------- Number of bedrooms _3__ Number of baths __�----- Lot size __ -I.-'______X_____4.(st�__ _______________ <br /> Water Supply: Public system ❑ Community system ❑ Private Nr Depth to Water Table Ir ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam [] Clay ❑ Adobe jr Hardpan [❑ <br /> Previous Application Made: Yes ❑ No'k New Construction: YesT No E]TYPE OF INSTALLATION AND SPECIFICATIONS: '1 <br /> (Na septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic,Tank: Distance from nearest welL___9b_.f_-_Distance from foundation-----Jf ____ _ Material <br /> ---------P.M <br /> No. of compartments---------2------------- ------Liquid depth__._____�}rr---____-_ CapaCapacity _ - /j_ <br /> � <br /> Dispose 'field: Distance from nearest well-----$Vf_Distance from foundation__-____�___i.....Distance to nearest lot line_____ <br /> Number of lines----------__2- __ __________Length of each hne__IQ4_.—_.�'0___..Width of trench----- -_-_.y..________ <br /> y�1 « <br /> Type of filter material i1X V444f___Depth of filter material_________-It--____.__Total length__-__.---___�__ _____________________ �. <br /> -Seepage Pit: Distance to nearest well----------------------Distance from foundation-----------.........Distance to nearest lot line__._________.--__ <br /> ❑ Number of pits----------------------Lining material--------.-.------------Size: Diameter------------------------Depth-----------------------.--------. � <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> El Size: Diameter--------------------------------------Depth------------------------------------------------.----Liquid Capacity-----------------------------gals. <br /> Privy: ` Distance from nearest well--------------------------------------------------Distance from nearest building-----.------------------------------------ <br /> 0! <br /> ._____._______________-.___-__._._.❑ - Distance to nearest lot line_______________________________ _ <br />��. Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------- <br /> _-. <br /> i. --------------------------------------------------------------------------------------•----------------------------------------------- <br /> ------------------------------------------•-•-------------------------------•-••---------------------------------------------------------------------------- <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, 54te laws, and rules,­and regulations of the San Joaquin Local Health District. <br /> (Signed). C`': ''_. ?__. '> -- ------------------------------------------ - <br /> --------------------(Owner and/or Contractor) <br /> - <br /> V:---------------------------------------•------- ----------------------------------------------------------------------------------•(Title)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, [ocation of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------------------------------------------------- DATE----------- <br /> REVIEWEDBY------------------------------- - ---------------------------------- - •-•---------------------- DATE----------------------------------------------- ----- <br /> .BUII DING PERMIT ISSUED-----------------------------•------------------------------------------------------------- ------ DATE--------------------------------------•------ -------------- <br /> Alter"" <br /> �atians end/or. recommendations:----------------------------- ---------------------------•----------------------•---------....._..----•------------- ------------------------------------- <br /> � ? t <br /> ... - __________________________.._____._..__-_______._____.___._._..__.__________________________________ <br /> r. ____:_____- ��__________ <br /> ... ,.. ___________---------------------- <br /> - -_____________....__________...._....___.______._ <br /> I --------- --- -- --------------------------------- <br /> {y <br /> _ ? 1 <br /> FINAL l #fb"N BY:.- = ` -------------------- --------------- Date- - - L//( - <br /> k, i.-._._ r <br /> SANiJOAQIlIN 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 /> . <br /> ES-9-20.i – <br /> ' Revised W-2100 <br />