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APPLICATION FOR SANITATION PERMIT Permit No. _ �/cribecl./ <br /> -___-_ <br /> (Complete in Duplicate) Date Issued ---- ---Applicationj hereby made to the San Joaquin-'Local Health District for a permit to construct and install the work her m de <br /> This application is made.in compliance with County Prdinance No.. 549 <br /> JOB.°ADDRESS D l OCAT N__ <br /> -------------------------- ----'-------------------.---- <br /> _ aa r <br /> Owne"r's Name---- -- ---- ---------------------------------------------------------------------- <br /> ------------------------- <br /> ---------- Phone-,, <br /> Address_-----------, f - -- -- ----------------------------------------------------------------------------------------------------------- ----------------------- <br /> 'Contractor's Name-- ------------- -- -------- - - ------------------------------------------------------------------------------------------ Phone------------ •------------_---- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---L/Number of bedrooms ___C___ Number of baths ---I--- Lot size ___ __X Q?______________________________ <br /> Water Supply: Public system .Z Community system ❑ Private ❑ Depth to Water Table ________ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoVNo <br /> Clay Loam ❑ Clay ❑ Adobe Hardpan <br /> } <br /> Previous Application Made: Yes E] No W New Construction: Yes ❑ <br /> TYPE OF INSTALLATION AND .SPECIFICATIONS: <br /> (No septic tank or cesspool permitted.if public sewer is available within 200 feet.) <br /> Septic ank: Distance from nearest wel&-�I— Dista ce fro fou ation_____�_�______.Mater' I ___________ ______ ___ dd <br /> r IV No. of compartments______ ___ -___,,__nn__nnSize _ X ____Liquid d++e} th__________ _________Capacity____L�-:� l--- <br /> Distance from nearest well__ X�Distance from foundati l Distance to nearest lot Jifie <br /> Dispos Field: - _. f�'�� tr. `iA t,--�-------- <br /> Number of lines_____________ _ ___-_-__ Length of each line___-!_-f�____`-__ _ Width of trench---_ __ --_-_ <br /> Type of filter materia _ _--___ p - g <br /> - - ------------------ <br /> --- <br /> - ------- <br /> -_ ____ e th of filter material_________ _ _=___Total length.- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line___-_______-_____ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------.------ <br /> t • <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------___.........-_-...... <br /> ❑ Size: Diameter---•----------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______________________________________-__. <br /> ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------- ------•- ---- <br /> Remodelingand/or repairing (describe)----------------------------------------------------------------------------------------- ------------------------------------------------­--------------- <br /> ------------•---------------------------•-----•---------------------------------------------------------------------••-----------------------•------------..._ <br /> ----------------------------------•------------------------------------- ---------.......---••----------------------- -----------•----------------------------------------•--------------•--------------------------- <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, Stalas, and rules and re ulations of the San Joaquin Local Health District. <br /> Ll (Signed)---- ------r�Cd. t ---- ----------------------------------------------------(Owner and/or Contractor) <br /> By=------------------------------------------------------------------------------------------- -----------------:(Title)---------------------- ---------------------------------------- <br /> (Plot plan, sho i 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 /> REVIEWEDBY------------------------------------- - -- -------------------------------------------------------------------------------- DATE------- - <br /> BUILDINGPERMIT ISSUED------------ ------------------------------------------------------------------------- DATE--------------�------------------------------------ - <br /> Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------•-----------------------------------------------------------------------------=--------------------------------------------------------------------------------------------------------------- <br /> -------------- <br /> ---------•-•-•------•---------------------------------------------------•------------ --------------------------------------------------------------------------------------------------------------___------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> FINAL INSPECTION BY:-------- ---____--_-- 4 — <br /> - ----- ----- -- - ----- 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 /> ES-9-21vl 8-51 Revised W-2100 <br /> F <br />