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APPLICATION FOR SANITATION PERMIT Permit No. ------ <br /> (Complete in Duplicate) <br /> Date Issued --- <br /> Application is4re-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 with County Ordinance No. 549. <br /> 11 <br /> JOB ADDRESS AND LOCATION----------- ----------- --------- <br /> ou <br /> h ne <br /> ------------ <br /> Owners Name----- -------- ------ ------ ----------------- - ----------- ---- P <br /> ------------------ ---------------------------------------------I--------------------------------------------------- ------------------­----- <br /> Address--------Y <br /> Contractor's Name_ ---------- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House El Commercial ❑ Trailer Court El Motel El Other <br /> Number of living units: I---- Number of bedrooms _4-__ Number of baths 1__--_ Lot size r j,4_7��- 7­_A_ <br /> Water Supply: Public system El Community system -El Private Z Depth to Water Table __V0 ff. <br /> Character of soil to a depth of 3 feet: Sand Ej Gravel [-] Sandy Loam El Clay Loam E] Clay El Adobe. -Hardpan E] <br /> Previous Application Made:, Yes [I No fZ New Construction: Yes El No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: i Distance from nearest well---____-_______Distance from foundation--------------------Material--------------------------------------------- <br /> of compartments--------------------------Size---------------------------------Liquid depih--------------------------Capacity--------------I <br /> 'I from nearest well_________________Distance-----------_D�stance from foundation--------------------Distance to nearest lot - <br /> Disposal Field: Distance line._______________----------------- <br /> ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of french---------------------------------- <br /> Type of.filter material-------------_----------Depth of filter material--------I---------,-----Total length------------------------------------- <br /> See'page Pit: Distance to nearest well_,9_S__4P--------Distance from foundation----�:_A--------Distyce to nearest lot 11 16.0, <br /> Number, of pits-------l ------Lining mate riaI_C&,t11-__9;�4Size: Diameter--------5--------------Depth------ <br /> Cesspool: Distance from nearest well------_---------Distance from foundation-------------------Lining material------------------------------------ <br /> El Size: Diameter--------------------------- ----------Depth--------------------------- -----------------Liquid Capacity----------------------------9 <br /> 11 <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------_-------------------- <br /> Distance to nearest lot line---------- ------------------------------------------------------•------------------------------------------------------ -------------- <br /> ❑ <br /> - -- -------- ---------- <br /> Remodeling and/or repairing {describe):-------- <br /> ....... ................------------------- -- -- --------- -----------------------------------------------­--------------------I—----------------------- 7-- <br /> ------------------- 5 i, <br /> --------------------I----------------------------------------------L-------­----------­I---------------------------------------------- ---------------------------------------------------------------------------------------------------------------------I------------------ <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 /> ----------------------------------------------------------------------(owner and/or Contractor) <br /> (Signed)....a_g�t---- Or -- --------Y_ <br /> By: :--------------------------•---------------------------------------------------------------------- ---(Title)----------------------------------------------------•----------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> F(?R-REPA�RTMENT.,USE ONLY <br /> ---------- <br /> "PLICATION ACCEPTED BY----- ---------- --- ----------- DATE-- <br /> -- --- ------ --- ---------------- --------i <br /> -RPIE1 ------------. DATE--------------------------------------------•--r------ <br /> WED BY---------------------------------------------------- ---------------------------------------------------------- ---- DATE ----�t------------------------------------ <br /> BUILDING PERMIT ISSUED----- ---------------------------------------------- LA__ -- ----- -­­ <br /> a.;�!------------- ---- ---- <br /> Iterations and/or <br /> - --- ------- -- <br /> A a- ------- -------- ------ 4 -------- <br /> A'------------------------ - ------ ---- --- -- ------- <br /> ---W�61f_,__77---- - - -- ------ <br /> -------4-Am:_ R------------I-- ------41------ ------ -----------------­ <br /> --------------- ---- -- <br /> ------- --- `' <br /> -------- ----------------- -- ---- ------------------ ----------------- -- - ----- <br /> --k _.T-- -- ------ - -- -------- ----- ----------------------------- ----------- <br /> NAL INSPECTION BY:--- ------------------ ----- -- ID6+6------------ ----------- ----------------------------------------------------- <br /> ��:A----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 We5f Oak Street 132 Sycamore Street 814 North ."C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 5-51 Revised W-.2100 <br />