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APPLICATION FOR SANITATION PERMIT Permit Nota-"-_a-------- <br /> (Complete in Duplicate) 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 is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATE NJ--------�4­3_3---------C- --t 2494E r <br /> / h ` Phone------------------------------------ <br /> Owner's Name------_-`•------ ------=-- �t �' ���"3$ -------------- <br /> I. <br /> ------------------- ' --...------- <br /> �Y G ------------- <br /> Address <br /> Contractor's Name__'----------------------------- -------------------- e�----- Phone----------------------------------- <br /> ir <br /> Installation will serve: Residence ,q, Apartment House ❑ Commercial ❑ Trailer�Co�urt ,❑ Motel ❑ Other ❑ <br /> f N..{ <br /> 11 `x '- ---------------------------- <br /> !Number of living units: -------- Number of bedrooms "�___ Number of baths _l__._ Lot size _.__-.-�-___�.__-- <br /> Water Supply: Public system Community system Private De; th to Water Table --__--- ft."( <br /> Y � ,I Y Y ❑ ❑ �p , i <br /> Character of sol! to a{depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay E] I Adobe' Hardpan ❑� <br /> Previous Application Made: Yes ❑ 'No W New Construction: Yes ❑, No,k l4 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> tank or cesspool permitted if public sewer is available within 200 feet.) . ' <br /> (No septic to p p <br /> � r - <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation-------f-----------.Material-_-_-_T-._--_.__._--------_._--_-_----_-._.--_. <br /> fNo. of compartments--------------------------Size--•-------------------------=---Liquid depth-------------------------.Capacity <br /> Dispos I Field: Distance from nearest well:`=— ------Distance from foundation--IQ --.__-.-----Distance to 'nearest lot line-_-__ <br /> Number ail lines--------------r__-- #-=`--- Length of each line------------`-----;i;_--.--Width of trench--------- -��--------------- <br /> Type of filter materia€__ .. __Depth of filter material" <br /> Seepage <br /> length__----------3J�______________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation__-_-_-----..--_--.Distance to nearest lot line-_.-----_----_- <br /> ❑ Number of pits---------------------Lining material ==:_Sizer=Diameter.- _ ------Depth-- --- <br /> Cesspool: Distance from nearest well___-_.___"Distance from foundation---.-.-...__------.Lining:material------------------------------_.--_. <br /> ❑ -; may.. . . <br /> c "� t �- <br /> Si F: Diameter_.- De ti ---- -- Liquid Capacity - 9a s. <br /> Distance from nee e t well---------------------- ------------------------ <br /> Privy: Distancefram nearest building-- -------------------------------------- <br /> Size: <br /> ----_-------------------------------. <br /> [j Distance to nearest lot line "--- <br /> ------------------- ""o. .�. . <br /> --------- <br /> Ile <br /> Remodel,n _.and/or. repair ng descrEbey:'Fd5SV---- -- ---------- ----- <br /> 3 <br /> 1. <br /> ' - ----- <br /> i G,;ryQ,� li'l.t •�,� r yr" - 1 �.�Z- <br /> : — rWL <br /> 3 <br /> • <br /> ------------------_________ _ ____ _i_ ------------------ ------------------- ---_-----•_-____----- ----------------------------------------.-------------------- <br /> _-_.-______-___._.________...___.__.____- <br /> I hereby certify that,! have prethis application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules a d regulations of the San Joaquin Local Health District. <br /> t <br /> f Contractor] <br /> Si ned r,-s� (Owner and/or Cont c or) <br /> { g ) -- - - <br /> BY:--------------------- -—IV (Title) ------------------ <br /> (Plot plan, showing size of lot, location of system in•relafion 16 wells, buildings, etc., can be placed on reverse side). <br /> `r FOR DEPARTMENT USE ONLY <br /> DATE <br /> APPLICATION. ACCEPTED BY----- ------------- ?;t.___ <br /> R j -------------- � ' <br /> REVIEWED BY - DATE <br /> --------- -------- - ---------- - ---- <br /> BUILDING PERMIT ISSUED--------------------------- <br /> - --- <br /> ------- <br /> ------------ <br /> --- <br /> --- <br /> --------------------- <br /> -------------- <br /> -------- <br /> -------- <br /> -------------- <br /> ---------------------------------- <br /> -- <br /> - DATE..---------------------- <br /> ---------- <br /> ---- - V <br /> �. ------------------- <br /> Alterations and/or.recommendations:. -------- ----- <br /> ---•--------- - -- -------- ----------------------------------4-----------;'-- , - - -- ------ <br /> ----- - ---- <br /> ----------------- }}/��f� <br /> / _ (��J� ------_-.- <br /> 3 �- � <br /> FINAL INSPECTION BY:.__ • C`r+:r�=w'< s Date----------------------------- ---- <br /> �o <br /> _l� <br /> - SAN J AQUIN 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 /> s <br /> ES-9-2M 10-52 Revised W2100 / <br />