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•� �� � � � �� �'! APPLICATION FOR SANITATION`PERMIT Permi# No. ' <br /> [Complete in.Duplicate) , �..� A <br /> _ to Issued � � <br /> Applicaa-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__. -_ <br /> Owners Name________ — ------ <br /> � - Phone--- _ -- •_---- <br /> Address ----_-------------------•-----------------------..._.. ••--------•----------------- • ---------------•-- - --- <br /> r7t <br /> % <br /> Contractor's Name-- _� -- - -�''�- ----------- ��-- .-----I- -----------• --- Phone.- ' <br /> ! II 1 1 i-�- i <br /> Installation will serve: Residence U? -House ❑ Commercial ❑ Trailer-Court ❑ Motel ❑ Other ❑ <br /> Number of living units ,_ ______ Number ofA1-e� or�oms_-'Number of'baths ot.size ____ . -S S� <br /> y--------_X ----------------- <br /> Water'Supplyt Public system [60eCommun`lity,s`ystem ❑ Private ❑ Depth to A 1ble.__y ft." <br /> Character of soil to a depth of 3 feet: ; Sand ❑ 'Grak ❑` Sand"Loam —Cla Abam Clay Adobe 1 <br /> r Y ❑ Y ❑ Y ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ NofT!_,�New,Construction.' Yes �o ❑° r <br /> TYPE OF INSTALLATION AND SPECIFICATIONS'- S <br /> •9 P _ s,p <br /> p, � j public sewer is available'within 2QQ feet) <br /> Septic Tank: Distance from pearest well__ a fir- .`.t.. - � � �� �� � -� <br /> No septic tank or cess ool ermined if. <br /> I Size Li uid Material ----------------- <br /> No. of compartments_•_-�__-.---- ------ Dr e- - from foundatiLq- __ depth ____.Capacity <br /> Disposal Feld: Distance from nearest well _.._...•_.---_-Da tante from foundation_____!_. .,_Distance to nearest lot line_______________ <br /> ❑ Number of: lines--:--- -`- -----.-___.!_-- ----Length of each line--------------------------- `Width of trench----------------------------- ---- <br /> Type of filter material__7��---_=_Depth of filter material__ 1­411-1.- Total length'--'-----------------------------________ <br /> Seepage Distance to nearest.we11�7DZ�-_Z Drsfance_from,,foundation `S1�__.___.Distance to�nearest lot line_.__S�_�___ <br /> Number of pits.----- _ -___--'Lining material -L..Size:.Diameter------ 6----- ---.Deptn_-:----.Z- ------------------ <br /> 1 - <br /> ----- 1 <br /> Cesspool: Distance from nearest_well-- --____ ---_Distane fro f�?undation_________________.__Lining material:__._.__.-___..._____-____-_____-___. <br /> ❑ Size: Diameter - - ----Depth_ - : - Liquid Capacity = gals. <br /> Privy: Distance -,rcm nearest �Ne[I- :--------_:_'__ ------ ---_nDistance'from nearest building------------------------------------------ <br /> ❑ Distance to nearest,lot line - -- -------- --- --- ----------- ------------- - <br /> �y <br /> Remodeling and/or repairing,(describe::.-- =" ' ° ' { _ - -------------------- - - <br /> .._'� <br /> ' - 4 ---------- <br /> rm- --f -. <br /> .. . <br /> ------------------- <br /> ---------------_____-------------------------------------____________________ ___________________________________________________________________�______-_�_.________________.________________------------------------------------- <br /> I hereby certify that I-have�prepared this application and that the work will'be done an.accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations ofAhe San Joaquin Local Health District+ ' <br /> (Signed) � I} r-- �• <br /> ai :-- -------------------------- -- 2(0er and/or Contractor) <br /> BY: -� '.�1.< -~��^ems• 7--­ <br /> (Plot plan, showingn size of lot,.Iocatioof system elation'to wells, be. placed on reverse side). <br /> r buildings, etc., can <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY =- V-59---------------- ------------ k DATE-------- <br /> REVIEWED BY--------------------------------------------- ... <br /> BUILDING PERMIT ISSUED----= - ----------------------------------------=-----------------------------•----•--------------_ DATE------- --------- <br /> Alterations and/or.recommendations:--------------------------------- ----------------------------------•--------------------•----------•----------------------- = <br /> ----------------------------------------------------- <br /> -----•----------------------------•----------•---•-"------ ----- <br /> ---------------------- --------- <br /> ia <br /> FINAL INSPECTION BY:____ - - --- ----------- - -� _--:=- Sir_ - - <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 Manfeca, California Tracy, California <br /> r � <br /> t ES-9-2M Revised W-2100 <br />