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APPLICATION FOR SANITATION PERMIT Permit No. �6__y______ <br /> (Complete in Duplicate) ,S �✓ ;; <br /> Date Issued/ <br /> Application 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 N . 549. <br /> - , <br /> JOB ADDRESS AND LOCATION a --- ---------------- /------- <br /> Owner's Name---- -•----- ----•--------------� �%�� ------------------------------------------------------------ Phone---- __lrl <br /> Address--------------------------------------------------- ---------:f----------- ---------------------------------------------- <br /> Contractor's Name16, Z1-------------- --------------- ,�/ft Phone <br /> Installation will serve: Residence [& Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---/-- Number of bedrooms 3__ Number of baths _-/--- Lot size ----------6_,9-------- <br /> Water Supply: Public system Community system ❑ Private 0 Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe DU Hardpan ❑ <br /> Previous Application Made: Yes ❑ No jK 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 /> No. of compartments _-Size__________________-___________Li Liquid depth <br /> ❑ pq P ------------------------ <br /> Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_________________ <br /> ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of french---------------------------------- <br /> Type of filter material-------------------------Depth of filter material------------------.---Total length------------------------------------------ <br /> .11 <br /> See <br /> ---------------------- ------------------ <br /> Seeps a Pit: Distance to nearest welLY __H---Distance fro fou dation__,; _______-Dista Distance to nearest'lot lines_-__---. <br /> Number of pits__________--____Lining material __________ ____Size: Diameter_._ _ ------.Depth:_,2_ __-________-_____ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material___: ------------------------- <br /> ❑ Size: Diameter--------------------------------------Depfh'-------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well_________________ ____________----_------------Distance from nearest building------------------------------------------ <br /> ElDistance to nearest lot line_- - ----------------------------------------------------------------------------------------------------------------------------------------- ' <br /> Remodelingand/or repairing (describe)=----------------------------•----------------------------------------------------------------------------------------•-------------------•-------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <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 ales and regulations of the an Joaquin Local Health District. <br /> �-. <br /> (Signed) l7 ---- - ------ ---------------------------------------------------------- (Owner a,d/or Contractor) <br /> r� <br /> By. - A`=f -- ----------------------(Title)--- 1 ------- --------------------- <br /> Plot tan, s wing size of lo+, loc ion of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> { p <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ----------- ---------•------------_---------------------------------------- DATE----,#'. <br /> REVIEWED BY-------------------------------- � --- --------------------------------- DATE �-a <br /> BUILDINGPERMIT ISSUED-----------------------------------------------------------•----------------------------------------- DATE. '4,-------------------------------------- <br /> Alterations and/or recommendations------------------------ ------------------------------------------------------------------------------------------------------------------------------------- ; ! <br /> -------------------------------•---•------------------------------------------------------------------------------------------------------------------- -------------------------------------------- --------... <br /> ------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------•-------------------------------------------------------------------------------- ------------------------------------------------------------------------ <br /> FINAL INSPECTION BY '� e- ------------------- Date------ --- - .�"'-------------------------------------- <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 /> l <br />{ ES-9-2M 8-SI Revised W-2100 <br />