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�.PPLICATION FOR SANITATION F <br /> -. ,,AIT Permit No. . <br /> (Complete in Duplicate) /// / <br /> Date Issued --__{ �.: `... <br /> Applica-1-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. <br /> JOB ADDRESS AND LOCATION-....?/4 -------------- - - <br /> _ --------------------------------- <br /> _ ..--••- -------------------- -- -- Phone- -- -------------- ------- <br /> Owner's Name.. �- <br /> Address-------------------------- --------------------------------- ----------------------------- -- - -----•-- -- -- ---- --- <br /> Contractor's Name -- -------- <br /> ------- -------- -- Phone <br /> Installation will serve: Residence V4--7`K_p­artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: --%__ Number of bedrooms -._ Number of baths .,C___-_ Lot size ---- 1.-..---------_____-- ...... <br /> .... .... <br /> Water Supply: Public system ❑ Community system ❑ Private Q---Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe L6' -1•lardpan ❑ <br /> Previous Application Made: Yes ❑ No n---'New Construction: Yes ❑ No d---- <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----.------------Distance from foundation_.__-------_------_Material-------------------------------------__. <br /> 01- No. of compartments- - -------------------Size--------------------------------Liquid depth.------------------------Capacity----- -------- <br /> Disposal Field: Distance from nearest well---U--_0-----Distance from foundation------,�__&... .Distance to nearest lot line.... <br /> Number of lines..-.---____/-_----__-_...__--._Length of each line.._.1_ ._ ____--------- of trench._,. ------_________________ <br /> V f !. <br /> Type of filter material.-.:_----------------_---Depth of filter material..... _Total length------,1._0----------------------- <br /> ._. <br /> Seepage Pit: Distance to nearest well-------------------- -Distance from foundation....................Distance to nearest lot line---------- --___ <br /> ❑ Number of pits----------------------Lining material-____ ---____--_ __. Size: Diameter-----------------------Dept h--------------__-------____ -_-. <br /> Cesspool: Distance from nearest well_____________ _-Distance from foundation ------------ Lining material----- -----------______----__El __ <br /> Size: Diameter---- --------------------------- -----De th-------------- --------------- ---- ----------------Liquid Capacity gals. <br /> Privy: Distance from nearest well--- --------.--------------------_-------------Distance from nearest building------------------------------------------ <br /> F] Distance to nearest lot line--- ----------------------_ ----------- ---------------------------------- - <br /> Remodeling and/or repairing (describe):-------------------------------------- -----------------------•---•-----------------------------•--•---------------•------------------------------------ <br /> ---------------•--------------------------------------------------•--------------------------------------------------------------------------------------------------•- -----------------------------------•-------------- <br /> -------•- ---•--•------- -- - ._- -- - --------•-•-----•--------•-•--------------------------•--------•--- -••----------------------------------------------------------------------------------- ----------•--- <br /> 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 /> r <br /> (Signed) -- ---- .:,_... --- - ------- -(Ownet_and/or Contractor) <br /> BY:------------------ =''e------------- -----------------------------------------------------(Title) ----- --- ----- ---------- <br /> (Plot <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----__---___-------- .- DATE <br /> REVIEWED BY-- ----------- --------- - -- ----- ---- DATE <br /> _s-�._-i--------------- --------------------------••---------- -.���--•----------------•--- -- <br /> BUILDING PERMIT ISSUED - = DATE ��. <br /> -- -- J^ <br /> Alterations and/or recommendations:. ------------------------------------•-------_-----•----------••-----------------------•-------�C------------------------ <br /> - - ----------------------------------------------------------------'----------.-----•---•------•------•------------•-•--------------•----------•--- ......_..------------------------------------------------....---- <br /> --- --1 -----•------------•-----------•----•----•-----------------------•--•--•---------•---•-----------.-•--- <br /> - - - - -------•-------------------------------------------------------------•-------------------------- --•-----------------------------------------------------------------------•--•-- -------------------------....... <br /> - - - - <br /> FINAL INSPECTION BY:. --------='--------------•- - ------- Date-• _111<---_------ <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 />