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1 APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) y Z� <br /> Date Issued _____--!!__r <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 County Ordinance No. 549. <br /> JOB ADDRESS A_ND LOC 7 ---- - ----- ------ - - -------- <br /> --------------------------------------------------------------------------------------- <br /> Owner's Name__ ----------------- Phone------------------------------------ <br /> Address....... <br /> .._.'2.. ._ ` <br /> -- --- ----------------------------------- <br /> Contractor's Name---- -------- --- ---------------------------------- -- ---------------------------------------- -•-------- Phone----------------------------------- <br /> Installation will serve: Residence [vpartment House ❑ Commercial [] Trailer Court 0 Motel ❑ Other ❑ <br /> Number of living units: umber of bedrooms __1---- Number of baths J--- Lot size --------------------------- <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2/ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feetd o <br /> Septic enk: Distance from nearest well�AaO_____Distance from,foun ion-`_ ateri lT____ <br /> No. of compartments--------- L__'--�.Size_3.-�_�_� --.Liquid depth---/ �----------Capacity___� <br /> Dispos ]"Field: Distance from nearest weld-30.0----Distance from foundation_/_f9---� istance to nearest lot line_t_� <br /> [ Number of lines of of each line-------------- <br /> of trench-----_-_-_?i.t_ _ <br /> Type of filter materia_ __ A ,� <br /> YP � --,---.�•Depthiof filter-material length_________________ 1�Q <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 /> ❑re _ V <br /> - Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-----------------------------gals. `- <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____________________________ <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------- \ <br /> ' Remodeling and/or repairing (describe}:--------- ------------------------------------------------------------------------------------- --•----------------------- --------•------------------- <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 I ws;)and rules and regulations,o.f_# a San Joaquin Local Health District. <br /> (Signed) - 'fir= r'' sof/ (Owner and/or Contractorl <br /> 8Y: (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 /> APPLICATION ACCEPTED BY-9-------------------------------------------------- y <br /> ------------------------------------------------- -- ---------------------------------------- DATE ------------•---------------------------------------- <br /> REVIEWED BY �7DATE_ --------------•-----------------•------------------- <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------------------- - DATE------ <br /> r4t-------------------------------------------------- <br /> Alterations and/or recommendations:--------=--------------------- -------- ----- --------- ----------------------------------------------------••-----•-------------------------------------- <br /> ---------------------­------------------------------------------------------------------------ <br /> -------------------------------------•-------------•----•----•-------------------••-•----------------------------------------- -----------------------------------------------------------------•----------------•----------------------------------------- <br /> -----•----------------------------------------------Q-------------------•------------------------------------------------------------------------------------------•-- ------------------------------------------------- <br /> -----•---------------------------------------------•--------------•-------------------------------------------•--------- ---------------------------------------------------------------------------------------------------- <br /> -----------------------•-------------------------------------- ------------------------------------------------------ -------------------------------------------------------- <br /> �C <br /> FINAL INSPECTION BY:----- --- 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 l..odi, California Manteca, California Tracy, California <br /> ES-9-2M Revises 1-57 F.P,CO. <br /> r • <br />