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APPLICATION FOR SANITATION PERMIT Permit I No_,� <br /> (Complete in Duplicate) <br /> Date Issued <br /> 3 <br /> Application <br /> is hi�reby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This <br /> application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATI N---- �........2.......r:57­2X/.414- - ---/----------------------------------- --- --- ----- <br /> Owner's Name---------`7*------ ----------- -- ----------- ----- - ---- ---------- ----------- ---I--------------------------------------.. Phone----- :7-------------- <br /> Address-...........----­------------ ---------- ------------ - -- ------- ----1---------------------•--------------------------------------------------- ---------------- <br /> Contractor's Name------------ t-------------------------------------------------------------------------------------- Phone----------------------------------- <br /> Installation will serve: ' Residence` <br /> esidence A artment House [:] Commercial El Trailer Court ❑ Motel ❑ Other E:j <br /> Number of living I— mber of bedrooms A- Number of baths )----- Lot size ----------------------- <br /> Water Supply: Public system Community system [3 Private E]' Depth to Water Tabled ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam []Loam ❑ Clay 0 'Adobe�rHardpan.1� 1 0. <br /> Previous Application Made: Yes [] No New Construction: Yes No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank;it, Distance from nearest well-________________Distance from foundation--------------------Materjal----- --------- - ------------------- ---------- <br /> No. of compartments--------------- ----&e--------------------------------Liquid clepth--------- - -- ---------- Capacity----------- <br /> Disposal <br /> apacity----------- <br /> D po Field,;. ..... . . 'stti n e________.Distance to nearest I I ii n e ............ <br /> is Sal eld, Distance from near tt wellwe ance from founda <br /> lines. Length of each line--- <br /> ------ ------------------ <br /> Number of ........ w..Width of french <br /> - �e--Depth of filter ma length-'--- <br /> fer materia-4�-/ material____,. __ ___.-Total/. <br /> Type of filter tri, -/Z-P------ - <br /> Seepage Pit: Dista'nce to nearest well---------------------Distance from f6undation-------------------Distance to nearest lot line______________.. <br /> El Number of pits ne$rest <br /> Lining material----------------- --Size: Diameter--.---------------------.Depth----------------------- -------- . <br /> Cesspool: <br /> ­1------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----______________.Lining material_____________-_____-______-__-______- 1 <br /> ❑ <br /> aterial-------------------------------------- <br /> ElSize. Diameter------------------ -------------------Depth-------•-----.-=----------------------------------- -Liquid Capacity------------------------- Z: <br /> Privy: Distance from nearest yell------ ----------------------------- ----------._Distance from nearest builaing------------------------------------------ <br /> El Distance to nearest lot line---------------- - ---- ------------------------------ ------------------------- <br /> -------------------- <br /> Remodeling and/or repairing (describe): ----------------------------- 2a� <br /> ---------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------:­---------------------------------------- <br /> ------------------------------------ - ------------------------------------------------------------------I------­­­­-----------------------------------------------------------------------------------------­ - -- - -C ( <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 pples and regulations of the San Joaquin Local Health District. <br /> (Signed)-- ---------P---�7c/6---------------------------------------------------------------------------- ......(Owner and/or Contractor) <br /> By:----------------------------------------------------------------------------------------------------------------------------- ------(Tif le)---------------------------------------------------------------- <br /> (Plot plan, showing 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 ByDATE-V�------------------- --------------------------------- <br /> REVIEWED BY----------------------------- DATE <br /> ---V <br /> -)---------------------------------------------------------------------------------------DATE---------Vv----=------------------------------------ -- <br /> ------------------------------------------------- <br /> -- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------—V-�v------------------------------------------ -- <br /> Alterationsand/or recommendations:—---------------------------------------------------------------------------------------------------------1.'e---------------------------------------------- <br /> ----------------------------------------------------•----------------------------------------------------------------•---------------------------------------------------------------•--------------------------------------- <br /> --------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------- ------I------------------------------------ <br /> -------------------------------------------------------------------------------- ------ <br /> -------------------------- ----------------------------------------------------------------- ----------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:--- • <br /> -------///SW6/4---------------------- Date----------- <br /> f�/ - <br /> - --------------------------------------------- <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 />