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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) Date Issued <br /> ------------------- <br /> Applica4ion is h reby 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 w. ifh County Ordinance No. 549. <br /> AL4 <br /> --- -- <br /> ----------- - -V..... <br /> JOB ADDRESS AND LOCA�)91\1_ <br /> ---------- <br /> Phone------------------------------------ <br /> Owner's Name------ 9 --- ----------------------- - -----------------------I-------•----------------------------- -- <br /> Address------------59 90 --------------------=-------- ---------------- ---------------------------------------I—------------------------------------............... <br /> ------------ --------- <br /> ------- -------------- <br /> Contractor's Name-------- -------------------- ------------------------------------------- -------- Phone----------------------------------- <br /> Installation will serve: Residence Apartm t House [I Commercial [j Trailer Court [I Motel F] Other [I <br /> Number of living units: __/---- Number of bedrooms .__Number of baths afhS ---/--- Lot size -------/---ca ------------------------------ <br /> —ft. <br /> Water Supply: Public system 0 Community system ❑ Private (Depth to Water Table S- <br /> ClayLoamo Clay [- Ado6e4r`HrdpanE] <br /> Character of soil to a depth of 3 feet: Sand [] -Gravel [] Sandy Loam E1 <br /> Previous Application Made: YesEl No Pk New Construction: Yes E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: I <br /> (No septic tank of cesspool permitted if public sewer is available within 200 feet.1 <br /> Se tic'Tank: Distance from nearest well----APO__Disfance from found on - ------ <br /> Materi l___________--------------------- <br /> No. of compartments---------- -;�-—----- ----Liquid depth------------ -------------Capac <br /> 01- <br /> Disposal Field. Distance from nearest well /0._!:�_Distance from foundation,/-------------- Distance to neard( <br /> Number of lines--------/------1r <br /> Length of each line----- ---Width of trench-0------------------------- <br /> ----- ------ Depth of filter material------ --------Total length-------- ----------------------- <br /> Type of filter maferiaI___t' <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line________-__-__._. <br /> ❑ <br /> ine----------------- <br /> 171 Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------- ---------Lining maferial-------------------------------------- <br /> -------------------------------------Liquid Capacity----------:-------:_:------ -gals. <br /> El Size: Diameter------- -------------------- ----------Depth--------.------- <br /> Privy: Distance from nearest well------------------------------------- ----------Distance from nearest building------------------------------------------ <br /> ❑ Distance <br /> uilding------ ----------------------------------- <br /> Distanceto nearest lot line.------------ ------------------------------I---------------------------------------------------------------------------------------------- <br /> Remodeling and/or airin desci;ibe):- --- _IZAA�-------------------------- <br /> es...... -----------------------I----- ---- ----------------- <br /> 4,----—---------- --V------- ---------- --- <br /> ­- ---- ----- -- --- - ------ <br /> --- --------------- <br /> - - ---- -- - ------ --------- ------------•- -------------- <br /> __T-----------------------------1-1-----------I---------------- <br /> ----- -------------------------------------------------------------------------------------------------------------------------------------------------------- . <br /> I hereby certify that Fhave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State. laws, and rules and regulations of the San Joaquin Local Health District. <br /> _,��K"c------------------------------------- ------------------------------------{Own®r and/or Contractor) <br /> d) <br /> (Signe' <br /> ---------------- <br /> -------------------------------------------------------- -------- ---------- ----------------- <br /> By:-------------_------ ----------—----- ------------------------ buildings, etc., can be placed on reverse side). <br /> (Plot plan, showing size of lot, location of system in relation to Wells, <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- ----------- DATE---- ----------------------- <br /> ----------XT <br /> --- DATE----- ---- --------------------------I---------- <br /> REVIEWED BY-------------------------------- <br /> --------------- ----------------------------------- <br /> BUILDINGPERMIT ISSUED--------------- DATE----- ------------------------------------------------------- <br /> Alterationsand/or recommendations------------------------------ ------------------------•------------------------------------••--•-----------------------------------•---------------------•--- <br /> -----------------------------------•---------------------------------------•----------------- <br /> ecommendafions:--------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------4---------------------------------------------_------------------------------------------------------------------------------ <br /> ---------------------- ------------------------------------ ------------------------------:--------- -------------------------------------------------------------------- ---------------------------------------------------- <br /> ---------- ------------------------------------- ---------------------------------------------------------------------------------------------- ---------------- ------------------------------------------------- <br /> -- --------------------------------- --------------------------- ---------------------------------------------------- -------- <br /> - --------------------------------------------------------- <br /> FINAL INSPECTION BY--------- ------ ------------------------------------------------ Date_...------------------------- <br /> ------------------------------------ <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 Manteca, California Tracy, California <br /> ES-9-2m Revised W-2100 <br />