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APPLICATION FOR SANITATION PERMIT Permit No. • , _______-------____ <br /> (Complete in Duplicate) Date Issued ---f L it <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 /> 1 <br /> JOB ADDRESS AND OCATION---- D __ <br /> 1. ------------------------------------------------------- <br /> Owner's Name -•_-- _-- _-- Phone p " <br /> y.. <br /> Address <br /> - ---- --------- --------------------------------------------------------•-•------------------------------------•-------------------------------- <br /> Contractor's Name--.--. <br /> Installation will serve: i Residence 1,Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: --- Number Number of bedrooms j_.__ Number of baths --f.--_ Lot size ____�T _J-1 -----_-_______________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table��_�_ ft." l.. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam' Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No�/ New Construction: Yes No F-1! /' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank.'or cesspoolFpermitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material-------------------------------- ___-__-____. <br /> No. of compartments--------------=------ --Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal field: Distance from nearest well-----------------Distance from fo`undation_____________4-_-__-Distance to nearest lot line----------------- <br /> Number of lints----------------------------------Length of each line-------.------_-------_f-----Width of french.---------------------------------- <br /> Type of filfer material-------------------------Depth of filter material----•------------------Total length------•----------------------------------- <br /> Seep e Pit: - Distance-to nearest well;,7%,d--------Distance from f dation ,a-.1-"..Distance to nearest lot line_____S T <br /> Nuh,'ber of pits Lining materia' 00, Size: iameter - ------------.Depth_.---- <br /> Cesspool: Distance from nearest well 'Dist from foundation.-.--.____________.Lining material--_____--------_----_______-_--- <br /> ❑ Size: Diameter----- `------------ -------Depth------------------=-----•--------- -----------------Liquid Capacity •--gals. e ' <br /> Privy: Distance from nearest well _________-----_------------------------------ __Distance from nearest building-_._-.-----_-_________-_______________.-. <br /> Distance to nearest:lot Eine - ---------------------------------------------------------------------------------------------------------- . <br /> Remodeling and/or repair; escribe):____ <br /> . - ------- <br /> - <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, S laws,`an ule and re relations of the San Joaquin Local Health District. <br /> (Signed)..----- ----- --------------------------------------(Owner and/or Contractor) <br /> `By:-- ... �--- ----------------- (Titl -` •---------------- <br /> [Piot plan, showing ' e of lot, location of system in relation to wells, buildings, etc., can be ed on reverse s' <br /> 4 FOR DEPARTMENT USE ONLY . <br /> APPLICATION ACCEPTED BY------------------- ------ ------------ -- - ------------------------------ ------------ DATE---------------- I. <br /> 1. <br /> REVIEWED BY DATE <br /> BUILDINGPERMIT ISSUED------------------------------------------- ------------------------------------------------------ DATE--------------------------- --------------------------------- <br /> Alterations and/or recommendarions:----------------------------------------------=-----------------------.--------------------------------------------------- <br /> �' f-------------------------- +-----41 - ---------•--•------ m <br /> --------------- ---- _+_...-•-------- <br /> ` h f �� --c. .. -, ---------------------- ------••----------------•--- <br /> --------------------------------------------------------------------------- ------------------ri-----:-------- <br /> -------------------------------------------------------------L---------------------------------------------------------------------------------------------- <br /> ---------•--------------------•-------------•----------------------------------------------------------------------------------------•------------------- <br /> FINAL INSPECTION BY.:------ - p__ -- Date--�--- /--7----�.5--- ------------------------ <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 - Revised W-2100 <br />