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APPLICATION FOR SANITATION PERMIT Permit No.� 16�4 <br /> ---------- - <br /> (Complete in Duplicate) 41-/,: d <br /> Date Issued <br /> Applica+ion is hereby made to the San �'baquin Local Health District fora 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 L0,QATION.. . .... -- ----- -------------- ----------------------- <br /> Owner's Name.------�Ih t ------- ----------- ------- ------------------- ---------------------- - - ---- ---------------------------- ------ Ph 'A --------------- -------- <br /> Address----------------bjo-- -- ----------- -------------------------- <br /> - -- ----------- ...I----------------------------------------------------------------------- <br /> Contractor's Name--_ - ----- .......JR-1--f------------------------------------------------------------------------------- <br /> ;7 <br /> Installation will serve: Residence g Apartment'House 0 Commercial 0 Trailer Court 0 --Motel 0 Other E] <br /> Number of living units: ---L Number of bedrooms Number of baths ___1__. Lot size --- ------------------------- <br /> Water Supply: Public system El Community system ❑ Private �pfh to Wafer Table--ya ff. <br /> Character of soil to a depth of i feet: . Sand E] Gravel 0 Sandy Loam E] Clay Loam E] Clay ❑ Adobe[21"Azirdpan 0 <br /> Previous Application Made: Yes E] No Er---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.) <br /> Septic Tank- Distance from nearest well_________________Distance from foundation--------------------Material----------------------------------------- ...... <br /> El No. of compartments------------ -------------Size--------------------------------Liquid depth---------------------------Capacity----- <br /> ------------------ <br /> D i s p o saField: ' Disfance from nearest well:________________---------------D'Istance from foundation-------------- .....Distance to nearest lot line_________________ <br /> ❑ Number of iines-----------------4 -----------Length of each line--------------------------------Width of french----------------------------------- <br /> I Type of filter material------- ---------------Depth of filter material----------------_-----Total length----------------------------------------.- <br /> Pit: Distance fo"n"6arefrom . .....Distance to nearest lot line----- <br /> Seepa, sf-.-7ell- -Disf' n�e "un.,,ation----140.1 <br /> - -7 #/-----Depth_ <br /> Number of pits-------y------------Lining materia Size: Diameter---�_ -0----- --_______ _--_- <br /> Cesspool: Distance from nearest weft-----------------Distance from foundation--------------r------Lining 'material_-_________.___.________.____________. <br /> ❑ Size: <br /> aterial------------------- <br /> Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-------------- gals. .�- <br /> Privy: <br /> apacity--------------- <br /> Privy: Distance from nearest well-----------------I <br /> --------------------------------Distance from nearest building--_____._________________---___ _ <br /> ❑ <br /> uilding---------------------------------E] Distance to nearest lot line:----------------------------- ------------------------------------------------------------------------------------------------------------------ <br /> Remodeling and/or repairing (describe):_------ -----------------I-----------------------------------------------I---------------------I-----------------------::-------------------------------- <br /> ---------------------------------------------------------------m-------- ------------------------------------------------------------------------------- ---------------------------------------------------------------------- <br /> ------------------------------------------------------------------------ ------------------•• ----------- -------------------------------------------------------7------------------------------------------------------- <br /> •---- -•------------ <br /> -------------------------------------------------------------- .....----------------•------------ ---------------------------------------------------------------------------------------------- -------------- - <br /> fi <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, Sfafela 'and rules and. r6gulaf*on, of the San Joaquin Local Health District. <br /> (Signed)--------------------- ---- ----------- -- ------- - ------ ------ ...... ----------------------- --------------------------------•- ------ and/or Coniractorl <br /> By:------------ ----- --- ---------- -------- -------------------------------------------------A------m---------(Title)-- -------------- --- 7�------------------- <br /> ............. . <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 /> 2" -------------------- <br /> REVIEWED BY------------------------------------- ----y-. --------:-----•------._------------------------------- <br /> - DATE--- _s— <br /> BUILDING PERMIT ISSUED----_-------------/1"t.............I---------------------------------------------------------- DATE------------------------- ----------------------------------- <br /> Alterations and/or-r'e6o'mmendations:--------------__------------------------------------------------- ----------------------------------------------------------------- --------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------4----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------­------------------------------------ <br /> ------------------------------------ ------------------ -----------:--------------------------------------------------------------------- <br /> ---- --------------------------------------------------------------------------- <br /> ----------- <br /> FINAL INSPECTION BY:-- .... ..... ------- Date------- ----------------------------------- ----------------- <br /> SAN <br /> -------I--------SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 30D West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />