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APPLICATION FOR SANITATION PERMIT Permit No. ._.. _:. <br /> (Complete in Duplicate) <br /> ate Issued --------- <br /> Applica{ion is hereby made to the San Joaquin Local Health District for a permit td construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> J <br /> i / f C S <br /> JOB ADDRESSAD LOCATION Z---- `- - /--V _104UAW C /� 1% <br /> at atL <br /> / ,AOwner's --•-- �•(�/• - - - - Phone?3L2__-;t_ <br /> ------------- •----------- ------------------------------------------------------- <br /> Address <br /> ---------- - <br /> Address---- •gy p 0- p r _ : <br /> r --- �� -----------------------------------------------------------­_------- <br /> Contractor's Name - ... ---------------------------------------------------------------------------------------------------- Phone'.....--.................. <br /> --- <br /> Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living '�_.-__ Number of bedrooms _ / 1 <br /> units: • �. Number of baths ._j__-- Lot size -------------------_ X_ <br /> X_ <br /> Water Supply: Public'-systemrl❑- -Co!m"unity systom'14"--PriJate ❑ Deptli to`Water Table73Sft. — - <br /> Character,of soil to a depth of-3 feet: a Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Z <br /> Previous lApplication Mede: Yes ❑ No 0< New. Construction: Yes ( No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> No septic letted if sewe <br /> tanVor cesspooprmipr is availble; ithi <br /> awn 200 feet.) <br /> Se y <br /> tic T ,.. ,l .,. _ <br /> Septic k: Distance.from nearest well- b-----_Distance founda;ion--- -�___:...M Val___________________._________ <br /> 4 "No. of compartments----- ' - ....Size---Z-- _ Liquid depth- ----------------Capacity--- ----- <br /> - ------------ <br /> D <br /> is osalF' Distance-from nearest.wail_. _-=Distance from foundation__J Distance to nearest lot �a--- ------------ <br /> p , <br /> Number of;lines___._t_____ <br /> f, �..--_�--.-_--Length .of each Isne_____��---f�_-.__---Width of trench --. <br /> --•------------------ <br /> Type of filter material___.;_ , Depth of filter material__-J _--_----_-Total length__- ------------------------------- <br /> Seepageh i - `e -- <br /> Number of: its.-_.---I_----______Linin �4'material----------------- Size: Diameter---_____--------_ ---- nearest lot line_----.------_-.-_ <br /> Pit: Distance`to nearest well....__-_.__-__--_-_Distance from foundation__________________ <br /> ❑ i P• 9 � <br /> Distance toDeptn--------------------------------- <br /> Cesspool: <br /> ----- ------------ <br /> .a.sspo0 <br /> Distari2b-.'from nearest-weil-----------------Distance from foundation--------------------Lining material_Y_.-.._---.--__--r_-_-_-_---.-__-_g_ <br /> Size Diam °Deptet - - Liquid, <br /> Privy:' Distance from nearest I'veli i---------------:------- --------- ---------Distance from nearest building---------------------------------------- <br /> El <br /> ---------. _ -___-_ ---_-----------❑ Distance to nearest lot line--n-----_� ------------"` ---------------------------------------. - ----------- ---------------------------------- <br /> t1 <br /> Remodeling and/or 'repairing (describe):_.._-°'__`_"'._ a <br /> k { I _ <br /> 1 --- <br /> ------------- ----- ------ ----- >-------------------- <br /> --.....------------------------------------------------- = <br /> ---- ---------------------------_ ---------------------------------------------------------------- <br /> .I <br /> ------------------ <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, St a laws, rules and,re ulatio of the San Joaquin Local Health District. <br /> E <br /> (signed)--• a <br /> r "- -- '- - ---• -•- •------- ------------------------------------- ---------------------------------------------------------------------------{ caner� nd/or Contractor) <br /> � .. .. - <br /> sy...... - -----------------------------------------------------------------------------=------------------------ ----- ------(Title)-•- = ---- ----------------- --------- <br /> (Plot plan, showing size of lot; location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> a FOR DEPARTMENT USE ONLY <br /> APP W TION ACCEPTED BY= ,� ------ DATE--- - --- --------------- <br /> REVEDBY. --------------7---------- DATE--------- ---------------------------- <br /> BUILDING PERMIT ISSUED------------- --=------------------------------------------ ---•---------------- DATE <br /> Alterations and/or.recommendations----- ------ --------------------•---------- --------------------•----•---------------------------------------- ---------------------------- <br /> --------------- <br /> = - <br /> j I <br /> ---- ------------------------------------------------•---------•----------••----------------------•--------------•--•---------------------- <br /> ---------`---------------•------- ----------------•--------- <br /> ----------------------= <br /> FINAL,fINSPECTION BY:... --- - --• -----------=--------------- '= -Date_- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a' <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 ; Revised W-2100 <br />