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xrI <br />APPLICATION FOR SANITATION PERMIT j Permii" No,, ------ <br />(tomp late in Duplicate) • hcate <br />Date Issued <br />F. <br />10) <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. d /Worvi <br />T <br />JOB ADDRESS AND LOCATION_ `'� z `� .....------. w ------------------------------------------- <br />... <br />Owner's Name 2 ' --- ��----- ---S = l ----�a Q4 0!Lj A#1�4�hone----------------------------- <br />- 1 <br />e__ ------------------------------------------------------------------------------------------------ <br />Address ---------------------=--=-••------------------------------------------ ------------- <br />Contractor`s Name-----€--------------------------------------------------------_c-`--------------------------------------------------------- Phone -------------- -------------------- <br />Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court 01 Motel ❑ Other ❑ <br />• Number of living units: ... Number of bedrooms -------- :Number of baths -------. Lot size............................._.__._....._...._-._-----.__._ <br />Water Supply: -Public system ❑ Community system ❑ Private 21' --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 />Previous Application Made: Yes M4"No ❑ New Construction: Yes ❑ No ❑ <br />TYPE OF INSTALLATION - AND SPECIFICATIONS: <br />(No septic tank "or cesspool permithed if public sewer is available within 200 feet.) <br />Septic Tank: Distance from nearest well-_ - V ----Distance from foundation..-�O_________ Materiel ------ .._._--__._.._. /............._.. <br />p Size--- ---Liquid dep-th-------------------------- Capacity_.____ / - <br />No`. of com artments.--.__'��-.-_ _____ � v-.� �_ <br />TDisposal Field: Distance from nearest well..... ---- from foundation...._-�foundation--- ...._.._Distance to nearest lot line. ................ <br />�✓ Number of lines.... -2 ......................._ Length of each line....-_----7-IL_-..-.�{....Width of french........_- _ r_.---------- <br />�` Type of filter material-_ ? -"..------Depth of filter material ....... . .. ... Total length......-_...._ '.Zs ..-..-_....___--. <br />Seepage Pit: Distance to nearest well ------- --------------- Distance from foundation _-.._-_-...__-__....Distance to nearest lot line -______._...__ <br />❑ Number of pits---------------------- Lining material ----------------- _---.--Size: Diameter ----------------------- Depth --------------------------------- <br />Cesspool:. Distance from nearest well.................Distance from foundation.-..-- ------------- .Lining material .....-----------------...__.._-.--._. <br />❑ Size: Diameter- ------------------- --------------- Depth --------------- ---------------------------- -----Liquid Capacity ----------------------------- gals. <br />Priv' .' Distance from nearest well --------------------------------------- -------- --Distance from nearest building <br />❑ Distance to nearest lot line --------------------------- ----------------------- --_-- ---- ', <br />Remodelingv.and/or repairing (describe):--------------------------------------------------------------------• ............... ---•-------------------- <br />-----------••- -----------------------------------------------•----------------------•--------•--------------------------------------------------------------------------------------------------- <br />--------------------------- <br />r t <br />------------------•------------- ---------------------•--•---------------------- ------------------------------•--------...------------------------------._------------------ --------------------------------------------- <br />------------ ­ ------------------------------------------------------------------------------------- <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, State lavws;'and rules and regulations of the San Joaquin Local Health District. <br />(Signed} ------ - --- ---•a ------- (Owner and/or Contractor) <br />.i . -' <br />{Title). <br />(Plot PI - <br />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 -------------- ---- ------------------------_ ...... DATE �`` �' - -------- <br />REVIEWED BY-------------'---------- - - <br />_. DATE-` = + ' -------=--- <br />----------- <br />BUILDING PERMIT ISSUED-----=------------------------ --------------------------------------------------------­­---•---- DATE ..=-------------------------- <br />------------------------------ <br />Alterations and/or recommendations:---------- , P-- <br />. <br />-- -- ---------------------------------- <br />- -- -. <br />µ <br />------------------------=--------------------------•------------------------------------------------------------------------------------------------------------ ------ <br />FINAL INSPECTION,-BY::r!-T-'r-----------= 1�--------- = = Date----------- ------- ----_---------- -------------------------------'----•---- <br />SAN JOAQUIN 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 Traey, California <br />ES -9-2M ' Revised W-2104 <br />