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1 APPLICATION FOR SANITATION PERMIT Permit No. <br /> - � {C(Complete in Duplicate) <br /> om p p } Date Issued <br /> Applica--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 /> T3 S -6- ,F(r CbGC_7-7 JG.+1 <br /> B ADDRESS AND LOCATION------- - - ----------------- - ---------------- <br /> - <br /> ------------ <br /> ee, <br /> OwnersName------ .. �------ ----------------------------------- . ... -- ---- ---- Phone--------------------•----- <br /> Address.--------- IV..... --------------------------------------------------------------------------------------------( -•----/------------- • <br /> Contractor's Name----- - ----- ,!' i --- - ---- y,1Ll 1 ---•--•--------------- Phone-/Y Q G ��GP d sem' <br /> Installation will serve: Residence Apartment House,❑ Commercial •❑ Trailer.Court E] Motel ❑ Other ❑ <br /> Number of living units: J--- Number of bedrooms __ .- Number of baths I� Lot size ---------------------------------------------- <br /> Water Supply: Public.system L] Community system ❑ Privateo Depth to Water Table _'_ -f ft. <br /> k Character of.soil to a depWof 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,@ Hardpan ❑ <br /> i Previous Application Made: :.Yes ❑ No ® New Construction: Yes No ❑ <br /> I TYPE OF INSTALLATION AND SPECIFICATIONS: E <br /> i { (No septic tank or cesspool permitted if public sewer is available within 200 feet.). D W <br /> Septic Tank: Distance from nearest well_--_ __-----_Distance from foundation-------Lo------- 1�d�, __---____. W <br /> [ No. of compartments......... ............ -- --- :_--Liquid depth---- -a--------------Capacity----- d-b------ <br /> -/ If <br /> Disposal Field: Distance from nearest well --_-d___.'Distance from foundation_____ .__._.Distance to nearest lot line_,,yfJ______- <br /> Number:of lines---------------J_,�_ ----___---Length of each line---------7 -y ......Width of trench------r.,�-�------------------ V <br /> Ty'e of-filter material.-. �..___ ��Depth of filter material__..__�`•�.._!___.Total length___.----7.5-_-_____ <br /> �- <br /> Seepage,Pit:.. Distance.to nearest'well' <br /> __/j4,�___.__-Distance fro f' d tion_=.JOd_------Distance to nearest lot line----1_Q_--- <br /> Number of pits_ ___V___ _____Lining material -- e: Diameter__--__- _-___--.Deptn___ --__________-___ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------.-----______-__-_. <br /> ❑ Size: Diameter ------Depth-------------------------=--------------------- Liquid' Capacity gals. <br /> Privy:; Distance from nearest well______________________�--.-__.__--.- <br /> __-___-____Distance from nearest building___________________ <br /> ❑ Distance to nearest 4ot line-------------------------------------------------------------------------: ----------------------------------------'__--------------------- <br /> Rema <br /> deling and/or repairing (describe):- = �j <br /> ---------------------------------------------------" -. ------••----• ------------------ -------_------------------------------------------------------------------------------- <br /> ----------------------------------------------------- --------=--- -----------------------------------------------------------------------•----------------------------------------------------------------------------------- <br /> t041 <br /> ---------------------------------------- -- -------- <br /> { 1/yf :. <br /> ! hereby certify th I have prepared Ais•application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State Ipos, jAid.rules.and regulations of the San Joaquin Local Health District. <br /> {Signed ...---- ------------- t - ------l------------------------------------------------ Ow er and/or Contractor) <br /> By:------•- - - ---;-------- ---( / ------------------------- ------------(Title)--------� ------------------------- <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 /> APPLICATION ACCEPTED;BY ------ --------------- ------- '-----_---------`------------------------------------- DATE-7---•----------------------------------------------- <br /> REVIEWED BY ` = = ---------------------`---------------=-"---- --... DATE A-A------------------------------------------------- <br /> BUILDING PERMIT ISSUED...................` - DATE. <br /> ---------------------------------------------- <br /> Alterations and/or recommendationr. ----•-------•--------------------------------------------------- <br /> '-� r I__.-.. _---- ` P x ..._-_-__.______.:__" .._____-: '`_________ ___________ "° --- -.---. .---- <br /> #� <br /> dJr#� `g^ `Sr..fi _.... "' yr.. ....". a°� r..:..t..-k– ' ------------------ <br /> -----•---'F a <br /> I'll' '' - - ----------•--------------------- - - ------------------- -------------------------------- <br /> I' <br /> Q ( C <br /> FINAL--INSPECTION--BY:. .- Date----- -------------=----------------------------- ---------=-------------------- <br /> p 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 /> i <br /> ES-9-21v1 Revised W-2100 <br />