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` APPLICATION FOR SANITATION PEROT Permit <br /> (Complete in Duplicate) <br /> Date Issued -.../ S` <br /> SeeDate <br /> is hereby made to the San Joaquin Local Health District for a permit to construct and install t ork herein described. <br /> This application is made in compliance with County OrdinaV No. 549 <br /> JOB ADDRESS AND OCATION . r .C�d+ v <br /> Owner's N me ------ ---- -- ----- - ------'----------------------------------------------- Phone- -- -------------------- <br /> Address......- ---- <br /> -- --- ------ - <br /> has <br /> Contractor's Name-------.-- r' - - : --------�------------ <br /> Installation will serve: Residence Be Apartment House ❑ Commercial ❑ TraiIlff r Court ❑ Motel ❑ Other <br /> �„ Number of living units: ---1--_ Number of bedrooms _�. Number baths 1_-1_'�Lot size _.�-Q.Q__-.X-f1�_�----------------------- <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 El Loam Clay Loam ElClay [I Adobe[I Hardpan <br /> Previous Application Made: Yes ❑ No L New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public Sewer is available within 200 feet.)f `f <br /> r. C / <br /> Septic ank: Distance from nearest well-0519 ou``,n,daatction._./.O.--'--.Mater' I_�"7.1d./:u(` -.-_-'//.-�, -. <br /> No. of compartments__---.__Zj__._.t._Size.�17..___ _z5p7_Liquid depth!..___, ------.---Capacity...�.r¢:9t/_-, e <br /> ` Dispos Field: Distance from nearest well-55.-O-4 Distance from foundation w �-.Distance to nearest lot jr}�._ --------- <br /> Number of lines---------- <br /> _- Length of each line---__.- ----_ -_----Width of trench.__ <br /> r- - <br /> Type of filter material.-'---' <br /> _-_- Depth of filter material-------- -- - <br /> &>f ....Total length__----_-- --„ -.......--------- <br /> Seepage Pit: Distance to nearest well__--:--._._.___-__Distance from foundation---..------------ _ <br /> Distance to nearest lot line_-..__--_-_-. <br /> r ❑ Number of pits...- Lining material. Size: Diameter----.-------------------Dept--..-............. -1 <br /> Cesspool: Distance from nearest well------_ Distance from-foundation ----------------Lining material-------- ------ <br /> ------ <br /> ------- <br /> _ 171Size: Diameter---------_---"----'-------------Depth---`-------------__---------------------------Liquid Capacity--------------_--------- \ <br /> gals. <br /> Privy: Distance from nearest well--------------.--------------------------------Distance from nearest building-------------------------- <br /> ❑ Distance to nearest lot line------------------------------`---------------__---------------_------------------------------------ - <br /> Re }pdelin and o repamn (describe):- .L_-X---- - - r <br /> 9 ----- -� --r - ------- - - - <br /> - -`�r------------- - ------------------- ------------ ----------------------------- ----------------- - <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 of the San Joaquin Local Health District. <br /> (Si ned J <br /> 9 )---- - - ---- --...,.. -------- - '"--`�"` ------t-_..---------------------- ._ ... -------(Owner and/or Contractor) <br /> By -------- M - t -.: -------(Title)--------------------------------------- - -- <br /> (Plot plan, showing size o lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- -------- ---------------------------------------------- -------------- DATE�P_-...------- - ------------_----------- <br /> ` REVIEWED BY-..---------------------- - - ------------------------------------------------ DATE S -------------- <br /> - --------- <br /> BUILDING PERMIT ISSUED...........--- ------ <br /> SSUED............._-..._._ -------- DATE....-----_---- � <br /> - - <br /> Alterations and/or recommendations-------------------------- -A..___ ___ -- -.-..-_.-----.-.--....---.---- -------Z_­,__.___----------------­----- <br /> - <br /> ` ---- ----------.-._-..------------------------------------------------.--------------------------------------------------------------------------------- --- <br /> -----------------_._----------------------------------------------------- ....._.------------------------------------------------------------------------------------------------------...... <br /> ------------------------ -----.. -------------- ------------------------------ ----------------------------------- ------- ------..----- .........------------ <br /> FINAL INSPECTION BY: - ------- Date-------.1..--- ;/ J - ------------------ <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak S+reet 132 Sycamore Street 814 North "C" S+reef <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> 40 <br /> ES-9-2M 8-51 Revised W-2100 <br />