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APPLICATION FOR SANITATION PERMIT Permit No- ----- <br /> (Complete in Duplicate) 3/ <br /> Date Issued ___.__ <br /> Applica+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 <br /> �/may <br /> JOB ADDRESS AND LOCATION = _- ---Ages------ <br /> ,�f <br /> Owner's Name `7+�- %4—-•-- !�!1'+j �r�set- --------------------•------------------- ------------------------------------------- Phone <br /> --------------- <br /> Address---­­­­.......­­-------•-------------------------------------- <br /> Contractor's Name--------- .. r' ------------------------------------------------------------------------------- Phone----------------------------------- <br /> - <br /> will serve: Residence ❑ Apartment House ❑ Commercial f o Trailer Court ❑ Motel ❑ Other ® 1WV"W' <br /> Number of living units: -------- Number of bedrooms -------- Number of baths ________ Lot size _1P 7_'__t__A7Co!----------------------------- <br /> Motel <br /> --_--_----_--_ __Motel ❑ Other ------- <br /> Number <br /> ___.-Number of living units,______,____ Number oflnedronms .� Gorhnna�rinriar_ _In+ Si a_ ' <br /> Previous Application Made: Yes ❑ No ® New Construction: Yes E No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-/47?--- from foundation__fd-----------Material -- _ <br /> ® No. of compartments--------- --------------size-�e2� ---- ------Liquid depth_. j., _-------Capacity_,rZ$'X_' '.._ <br /> Disposal Field: Distance from nearest well. /a A.'__Distance from foundation_-/d ----------Distance to nearest lot line---Z*.,_______ <br /> ] Number of lines---- --------------- Length of each line--__�QQ -------Width of trench---2_ --------------------- <br /> yp -A Depth of filter material___a_'__________Total length___A✓A7?_`________________..__.___ <br /> 7 e of filter material-�r._ __ . . __ <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-------------------- material--------.---_____-__________________ <br /> ❑ Size: Diameter----------------------- ------ -------Depth---•-----------------------------------------------Liquid Capacity---------------------------gals. _.a <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building <br /> ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------•--------------------- <br /> Remodelingand/or repairing (describe):----------------------------------------------------•----------•-------•--------------------•---------------------------------------------------------- <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, and rules and regulations <br /> of the San Joaquin Local Health District. <br /> (Sign(Signed)---- - --------�- `�`? .� " ' 40 <br /> ed) and/or Contractor) ; <br /> By: <br /> Y• _ ----------------------------------------------------------•--------(Title) +o 4 ---------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on rev r side]. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ='' ------------------------- DATE---,�------_--r4C <br /> REVIEWEDBY------------------------------------------------------------------------------------------------------------------- ------ DATE-------- <br /> BUILDINGPERMIT ISSUED----------------------------------- ------------------------------------------------------------------ DATE--------------- -------- <br /> Alterations and/or recommendations---------------------- ------------ ----------- ---------------------------•--------•--------------------.-_--.-------------•-•------------------•------------- <br /> --------------------------•--------------------------------------------------------------------------------------..------•-----------------------------------....---------. ---------------------------------------------- <br /> one <br /> FINAL INSPECTION BY:--- ----------------- Date_..a ..................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16:South American S+rest 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreat <br /> Stotkton, Cafifornia Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />