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APPLICATION FOR SANITATION PERMIT Permit No. ------ <br /> tv, (Complete in Duplicate) 9 <br /> Date Issued ...... <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance, <br /> ompliance with County Ordinance No. 549. <br /> !I <br /> JOB ADDRESS AND LOCATION ... .. ---------oi�------ - ------------------------------------- <br /> Owner s Name------ I---Z/� ------ Phone------------------------------------ <br /> ------------------------------------------------------------------------------------------ <br /> Address----- ----------- Zx i ------------------------- <br /> Contractor's Name----,-,, v <br /> Z? �_ -------------------------------------------------------------------------------------------------------------------------- Phone------------------_------- <br /> Installation will serve: Residence � Apartment House El Commercial E] Trailer Court ❑ Motel E] Other [] <br /> Number of living units: _r___-__ Number of. bedrooms Number of baths Lot size i`'_________-___________________________ <br /> Water Supply: Public system E] Community system [_1 Private M Depth to Wafer Table --- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam J-] Clay Loam E] Clay [-] Adobe M Hardpan 0 <br /> Previous Application Made: Yes E] No R] New Construction: Yes M No El FHA/VA: Yes [] No 0 <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 weh----4~q-----Distance from foundation---�_!?----------Maferial-j0-1-11!4�_ ----- - ------------- <br /> No. of compartments--------------------- -----Size--- ------------Liquid depth----Y--------------- Capacityl -------- <br /> Disposal Field: Distance from nearest well--4-0 Distance from foundation---Ya ---_-----Distance to nearest lot line__✓--------- <br /> Number of lines Length of each line-----4 ________.Width of ---------------------- <br /> Type of filter m ------Depth of filter material------1 '-- .--------Total length--- <br /> -------------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation---_...............Distance to nearest'lot line------------------ <br /> El Number of pits----------------------Lining material---------------------..Size: Diameter------------------------Depth----- --------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------- material__.___.__--_____________.___________ f <br /> ❑ <br /> aterial------------------------------------- <br /> El Size: Diameter-------------------------- Depth----------------------------------------------------Liquid Capacity------- -------------------gals <br /> Privy-. Distance from nearest well-------------------------------------------------Distance from nearest building____.._.____________:__________.___---_0 <br /> ElDistance to nearest lot line-- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):---------- ---------------------------------------------------------------------------------------- ----•------...._._------- ------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------I------------r---------------------------------------------------------------------------------------------- ...... <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, ate laws, and rules andrulations of the San Joaquin Local Health District. <br /> 1'/ <br /> -------�- --- ---------------------------------- ----------------------------------------(Owner and/or Contract <br /> Sy:--------------- ------------------------I-------------------------------------•------ ---------------------------------------(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 /> APPLICATIONACCEPTED BY-- - - - ------- --------------------- ------------------- ---------------------------- DATE-------------------------- ---------------------- <br /> REVIEWED BY--------------------------------------------- -------------------------------------------------------------------------------- DATE------------------------ ----------- <br /> ----------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations:-.------------------------------------------- ------------------------ ............­---------------------------------------------------- <br /> -------------------- <br /> ----------------------------------- ;i--- ::::-::----------------------I——----------­------ <br /> lew ------------------------------------------------------- <br /> -------- -------------------------- <br /> --------------------------- <br /> -------------------------------- ------------------------------------ --------------------------------------------------------------------------------ip------------------------------------ ----------------- <br /> -----------------------------------------------------1----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> r <br /> FINALINSPECTION BY------------------ ---------------------------------------------- Date----------- ------------------------------- -------------------------i------- <br /> SAN <br /> -------------------------i------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street (32 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revisea 1.57 F.P.CO. <br />