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APPLICATION FOR SANITATION PERMIT Permit No. <br /> [Complete in Duplicate) -7 1 <br /> --------------- <br /> Date Issued <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 /> - ---------------------- ------- <br /> ------------------------------- <br /> JOB -- <br /> - <br /> ------ <br /> JOB ADDRESS AND LOCATION------------------- -------------- <br /> Phone------------------------------------ <br /> 'Owner's Name------------- ---------- �. <br /> Address == --------------------------'------------------- ------------- <br /> ---------------- ------------------------•--- <br /> 1 I— <br /> Contractor's Name--•'-�--•------•----------------- - -------•--- •• --•------------------ ---------- ------ <br /> --------------------------------------- <br /> Installation will serve:' Residence Apartment House 171Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _--'____ Number of bedrooms -------- Number of baths ___1__. Lot.size _______ __ <br /> Water Supply: Pubiic,system [ICommunity system ❑ Private ❑ Depth to Water Table ____::__ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Y- Previous ApplicationvMade: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from found ation-----------------.-Material-------- <br /> -----_----------------------.------------ ( ,1 <br /> No. of compartments Size <br /> ----------------------Liquid depth--------------- -------- Capacity----------------------- <br /> Disposal Field: Distance from nearest well_.--------_-------Distance from foundation------------------._Distance to nearest lot line----------------- <br /> ❑ Number of lines--------------------------------- Length of each line------------------------------Width of trench.---------------------------------- <br /> , <br /> Type o. filter material-------------------------Depth of,filter material-----------------------Total length------------------------------------------ <br /> 'from Pit: Distance to nearest well____________.._g. Distance from foundation____________________Distance to nearest lot line____--___________ <br /> Number of pits------=------------- <br /> nearest well--------------- -Distance from - -----Size: Diameter----------------------.Depth <br /> -------------------------------- <br /> Linin material--------------- <br /> Cesspool: Distance from foundation____________________Lining materia _____._-.__,___ _::---_.___________ �' + <br /> De th------------------------------ ------Liquid Capacity------------- ;--•-- gals. <br /> ❑ Size: Diameter- ---- ------ ----------- ----------- p <br /> r y: <br /> Distance from nearest well----___._._____ j-0------------------ <br /> Py--Distance from nearest building-_____ -__ Q------------=--- <br /> +� -- ------------------------ <br /> ' -Distance to-nearest lot line--------'----------------------- - .. r <br /> j Remo cling and/or repairing (describe)--------------------------------------- ------------------------------------------- <br /> ----------- <br /> --- <br /> -----=------- :... <br /> i ------------------------------- <br /> ---•---$----------------------------------------------------------------------------------- <br /> ----------------------------------------------------------- <br /> ---------------------------------- ..---. <br /> --- --------------------------------------- •---------------- <br />` Thereby certify that l have prepared this application and that the work will be-done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> 1 � M r� ---- Hari and/or Contractor) <br /> �.__ :...•Signed) ---------------------=--------------------------------------------------(O"' <br /> f` By:-------------------------------------------------•:------------------------ ;-_-------------------=_-------------------------------(rifle)---------- ----'-_--•---------- ------------------------------- <br /> t (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ..-- DATE �"°� r ,� - <br /> - <br /> ---- <br /> REVIEWEDBY---------------•------------------------ ------------------------------------ ;- -------------------------------------- <br /> ----------------- <br /> ------------------------------------ DATE <br /> 4 ---------- DATE------ ----------------- --------------- -------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------- ---------------------------------------:---------- <br /> Alterations and/or.recommendations----------- ------------------------------------------ ---- --------------------------------•--------•• - - <br /> y <br /> - -- /� <br /> .y � <br /> = �. ` <br /> ------------------------------------------ <br /> --------------------------------------------------------- <br /> ------------------------------------------------------------------ <br /> ------------------------------------------------ <br /> ------- <br /> I FINAL-INSPECTION <br /> Date---- ..... ''fr.-------________ ________••--------•------•---- <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 300 West-Oak Street 132 Sycamore Street 814 North "C" Street <br /> 130 South American Street I <br /> Lodi,`California Manteca, California Tracy, California <br /> Stockton, California ' <br /> ES-4--2M Revised W-2100 <br />