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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) %'�� <br /> ' <br /> Date Issued _____ __S`�_-___ <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 LOCATION-------- - , --- ---- --- ter. ...--- ---------------------------- <br /> Owner's Name--------- - ------- - - - ---- -----_-- 12--- ----------------------------------------------------------- Phone �t <br /> Address ----- --------- - ----- ------------------------------ -------------- <br /> - ------ - -- <br /> ----- -- -------------- <br /> Contractor's Name----- - 1 1 ---- ------------ Phon . .V__ ,`_ �,/ <br /> Installation will serve: Residence Apartment Douse ❑ Commercial ❑ Trailer Court ❑ M tel ❑ Other ❑ <br /> Number of living units: __{__ Number of bedrooms _ __ Number of baths ,�11ff ' --`` / <br /> Lot Size ------- ---V------x•_1.2_ `•--•---••------- <br /> Water Supply: Public system Com,munity system ❑ Private'❑ ` Depth to Water Table eft: <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E 1=ardpan ❑ <br /> Previous Application-Made: Yes ❑ No �] New'Construction: Yes'❑ -No Uj,--FHA/VA: Yes Ll— No -- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ' <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) . <br /> ncfT k� Distance from nearest well_________________Distance from foundation-_._y---------------Material________:---------------------------------------- <br /> IiAp <br /> Ize <br /> No. of compartments----------- - - -----------Size----------------------------•---Liquid depth-------------------------Capacity--•-------------------- <br /> D• osal iel Distance from nearest well___------------__Distance from foundation------_____---------Distance to nearest lot line___-_-__-- <br /> Number of lines----'-----------------------------Length of each line------------------------------Width of trench.----------------------------- �_ <br /> Type of filter materia------------------------ Depth of filter materia l-----------------------Total length-------------------------------,-___--_' <br /> Seepage Pit: Distance to nearest well_A10—--------Distance from foundation ) -.: Distance to nearest lot line.__N.r_____-: <br /> Number of pits--.--/-------------- material _ <br /> -------Size: Diameter____e�_15-��___..Depth__. _ <br /> Cesspool: Distance from"nearest.well-----------------Distance from foundation--------------------Lining material_-____._.___-_______._.___.__._______: <br /> ❑ Size: Diameter-- --.---t------- --'-Depth------------- - x------------------I---------------Liquid Capacity- ------------------------=-gals.' <br /> PrixPrivy; stance from nearest'well---------- -- =--------------------------------Distance from nearest building-I----------------------------------------- <br /> ❑ Distance <br /> to nearest•lot-line------------------------------------------------ - _ _I �.� <br /> Remodeling and/or r ,.airm describ ------------- ------------------------ ------��- ----------------------------------------------------- <br /> ---- <br /> ------------------------------------------------------------------------------------------------r=;------------------------------------------------------------------------------•._----•---------------------------------- <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 tate laws, and rules and regula+ions of the San Joaquin Local Health District. <br /> 5i ned J <br /> ( g )-------- --------{�--��#Q -- �-��--js,�buildings, <br /> 4"d -------�f-----------------------------------��r Contractor) <br /> By: --------=-- ° ' <br /> Y ----------------•------------------------------------------- - ---- ------(Ti+le)------------------------------------•-------- ----------------- <br /> (Plot <br /> ------ ------- <br /> (Plot plan, showing size of lot, location of system in relation to , can be placed on reverse side). <br /> i <br /> FOR DEPARTMENT USE ONLY f <br /> /APPLICATION ACCEPTED BY------- -------- ----------------------------------------------------------------- DATE------ . - - -----------------•------- <br /> REVI EWED BY ----------------- I <br /> QATE <br /> BUILDINGPERMIT ISSUED----------------------------•----------------- ------- ---------------------------------------------- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations---------=---------------------------------------= --------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------ <br /> -------------------------------------------------- ---­----------------------- -------------------------------------------------------------------------------------------------,...----------------------------- ------•--- <br /> FINAL fNSPECT�pN BY..-- ------ -- -- ---------- ` ` Date __ 5--- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wes* Oak Street 132 Sycamore Street 814 North "C' Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M , Revised 1.57 F.P.CO. 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