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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) I <br /> Date IssueA/tV <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe l'oi5d all t er in escribed. <br /> application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION...... ------- <br /> - ------ ------------------ - -- ---)E, el-e <br /> Owner's Name--------- P/7- P I <br /> ---------------------- ------- 4,_ ---- ----------- ----------------L---------- Phone---------------------------------- <br /> Address-------------------------------- 149--f/.. ..... <br /> Contractor's Name______.....____.----------------------------- *�k.c---------------------------!----------- Phone----------------------------------- <br /> Installation will serve. Residence 0 Apartment House F1 Commercial E] Trailer Court 0 Motel El Other El <br /> Number of living units: Number of bedrooms ?_- Number of baths __/__ Lot size _____ ___ +_________________________<_______..__.__ <br /> Water Supply: Public system E] Community system E] Private X Depth to Water Table ft_ <br /> Characterof soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Lo Clay Loam E] Cla 0 Adobe ❑ Hardpan E] <br /> Previous Application Made:.'Yes ❑ No Ej New Construction: Yes E] No Ej C_42 ffs �N <br /> ._aFE_OF INSTALLATION AND SPECIFICATIONS: 117 <br /> (Wo septic tank if public-sewer is available wifhin-.200feet. <br /> Septic Tank: Distance from nearest well___��_'��' Distance from fou.ndaflp .__ _?6••Maferial_.T' <br /> ------------------ ------------------ <br /> No. of,compartme;t,-7_7 ___ _?------------�Size------ -.'Li;uid depth-------------f------------Capaci( <br /> 'y <br /> Disposal Field: Distance from nearest well_ _19111____ 'I <br /> 1)"sTance-from foundation_/_/).2Tr—_.Distance to nearest lot line--- --- --- <br /> Number of iines-----------A...... Length of each line____ I--tr----.Wiclth of french--------------------------------- <br /> .0 <br /> Type of filter Depth of filter material------ -------Total length___-___-A------------------------ <br /> Seepage Pit: Distance to nearest well----------------------Distance from -foundation--------------------Distance to nearest lot line----------------- <br /> F-1 Number of pits----------------------Lining material-•--------------------.Size: Diameter-----------------------Depth..------- ---------------------- <br /> Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material------------------------------------ <br /> ElSize. Diameter -------------------------- ---Depth----------------"---------------- ------Liquid Capacity------------------ gals. <br /> r� <br /> Privy: <br /> apacity------------------- <br /> Privy: "Distance from nearestwe­II_'____------ ___--`_____::'____________________Distance <br /> --------------- <br /> ------- ------------Distance from nearest building________.___.________-_______._._.__..._. <br /> -- <br /> EJDistance to nearest }ot line--------- ------------------I------------------------------------------I-------------------------------------------------- ------------------ <br /> Remodeling and/or repairing (describe):-------- ----------------------------------------------- ------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- - <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 rules and regulations of the San Joaquin Local Health District. <br /> —------------------------------------------------------------------------- -------------------------------------------(Owner and/or Contractor) <br /> BY:---=— -- —.-I- . <br /> ------- ------------------------------------------------------------------------------—-------------(Tif le)-------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). <br /> FOR DEPARTMENT USE INLY <br /> APPLICATION ACCEPTED BY_______ - ----------- ----- DATE---:---. -�.�� ----�--�'---•-------------- <br /> REVIEWED <br /> ATE------ <br /> REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------- <br /> Alterations and/or recommendations------------------------------------------------­------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------- -------- ---------------------------------------------------------- --------------------------------------------------------------------- ------ <br /> --------------------------------------------------------I--------------------------------------------------------•-- ----------------------------------------------------------I-------------------------------------------- <br /> ---------- ------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- -------------------------- <br /> -------------------------------------- <br /> ------------------------------------- ----------------------------------- <br /> FINAL INSPECTION BY:-------------- ------ ---------- - ------------ 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-9-2M 10-52 Revised W-2100 <br />