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APPLICATION FOR SANITATION' PERMIT Permt No. A--,(-- ------------ <br /> (Complete in Duplicate) <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. isImade in compliance With-Co nt .1,Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION. --- - -- ----j0 hioL----or"r'------- ------ <br /> Owner's Name----- flx_c...... - -- - ------- ------------------------------------------------------------------------ Phone---1 -f = <br /> Address <br /> hone---Address--------------1_3­3­3 <br /> Contractor's Name------_--- ----- ----------------------------------------------------------------------------------- Phone-----------------------------`----- I <br /> Installation <br /> hone----------------------------------- <br /> Installation will serve: Residence f Apartment House 0 Commercial 0 Trailer Court El Motel D Other El <br /> Number of living units: --- Number of bedrooms -k Number of baths __j___Lot size <br /> Water Supply; Public system_E] Community system F1 Private 9 D.epfh to Water Table -------- ff. <br /> Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam E] Clay Loam 0 Clay n Adobe V Hardpan ❑ <br /> Previous Application Made: Yes 0 No ;k New Construction.. Yes 9 No F1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> # <br /> Septic Tank: Distance from nearest well--,Soo------Distance from foundation_____/d_,____. <br /> No. of compartments--- <br /> -------------Size--- Liquid depth---------I-Or- -------Capacity_ A:hn"'---- <br /> ---Al----------- #1 <br /> Disposal Fiefd: Distance from nearest wellfoundation____ e cr- <br /> Distance from 0-11--------Distance �o nearest lot I <br /> Number of lines_______.__ Length of each line----------I-ID-0-----------Width of french........rX------------------- <br /> x I fa_... - <br /> Type of filter maferiaI!X__*�k____De`p'th of filter material--------/40-- -Total length----------1-10-0------------------ <br /> Seepage Pit- Distance to nearest we)l---------------------Distance from founclaflon-----------_......Distance to nearest lot line_________-___-_ <br /> ❑ <br /> ine----------------- <br /> 0 Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth------------------------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------- --------- Lining material_-__--_______________._____ <br /> ❑ Size: <br /> aterial---------------------------- <br /> Size: Diameter-------------------------------I-----;Depth------------------------------------------------- Liquid Capacity---------------------- <br /> Privy: <br /> apacity---------------------- <br /> Privy'. Distancefrom�nearest well______________ _____Distance from nearest------------ <br /> building------------------------------- <br /> El Distance to nearest lot line------------------------------- <br /> ------------------------------------------------------------I------------------------------------------ <br /> Rem, odeling .and/or repairing (describe):I---------------------------------I- ------- --P --------------------------------------------------------------------------------------------------------1". <br /> ------- - <br /> -------------------­--------- <br /> ---------------------------------------------------1-1--------------------------------------------------------------4P------- <br /> -------------------------------------------------------------•----•------------ <br /> - <br /> --------------I------------------------------------------------­­­---------------------------------------------­------­­----------------------------- <br /> ------------- <br /> --------------------------------------------------------------------------------------*--------------------------*--- -------------------------------------------------------------------------------------------------------- <br /> ."'. 14� <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, Sfaf2�Nand r <br /> As and regulations of the San Joaquin Local Health District. <br /> (Signed)- ----------------------------------------(Owner and/or Contractor <br /> ------- -------------*----------------------------------------------------------------- ---------------------------- <br /> by:----------------------------------------------------------------------------------------------------------------------------------(Title)--------------------------------------------------------------- <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 BY--------- -- -----------------1-....... ------------------ DATE <br /> REVIEWEDBY------------------------------------------------------------------------- ---------------------------------------------------- DATE <br /> -------------------------- <br /> BUILDING'PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE <br /> Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------- ------------ ------------------------------------------------------------------------------------------------------- --------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------- ----------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------=-------------------- ------------------------------ <br /> ---------------------------------------------------------------------f-________.______________________ _ <br /> --------------------------------- ------------------------ -------- -------- <br /> FINAL. INSPECTION BY--j ----- ----------------------------I------------------------ Date---- --- - <br /> ------------------------------ --- --- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />