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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued ---- <br /> Applic&ion is hereby made to the San Joaquin Local Health District for a permit to construg0and install the work herein described. <br /> This application is made in compliance with County Ordinance o 5>49. <br /> JOB' - -ADDRESS AND LOCATION--- <br /> ----- - - <br /> Owner's Nam ----- <br /> -------- ------------------------- --------------------------------------- <br /> Address. <br /> -- - - --------------- - ----------- <br /> Coh4actor s Name �.... - <br /> ----------------------------------------------------------------------------------------------------P--h-o---n-e----- <br /> ------------------ <br /> ---- ........ <br /> Installation will serve: Residence xApaFnent House F Commercial ETrailer Court j Motel : Other E <br /> Number of living units: --.Z- Number of bedrooms ,t9t_ Number of baths __/. Lot size AP_9!50Q_>(m9 ----------------- <br /> Water Supply: Public system El Community system F] Priva 1� Depth to Wafer Tablej�/ f. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy Loom [-] Clay Loam El Clay El Adobre,K Hardpan F] <br /> Previous Application Made: Yes F] N '� New Construction: Yes 0' N <br /> TYPE OF INSTALLATION AND SPECIZATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest w <br /> -------Distance from foundation/y_-_.______.M%.._.________ <br /> ial _�__3 -- ------ ---- ------ <br /> No. of compartments.._Y—-----------------Size4l.,��--- ------------Liquid depth_ Capacity----- <br /> _ -01__Z�-_ <br /> Disposal Field- Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line______________._. <br /> Number <br /> ine----------------- <br /> Number of lines-----------------------------------Length of each line--------------------------.-.Width Width of french----------------------------------- <br /> Type of-filter material_________________________Depth of filter material----__--------------To+al length____________- _-___-________________--- <br /> Seepa <br /> ength------------- ------------------------- <br /> eepa Pit: Distance to nearest welL.--------------------Distance from foundation_........___..__....Distance to nearest lot line__________._____ <br /> I Number of pits----------------------Lining material-----------------------Size: Diameter---------_-------------Dept k-------------------- ---------- <br /> Cesspoo Distance from nearest well--------- -------Distance from foundation___.________.__.___ Lining material___._____________ <br /> ------------------ <br /> El Size: Diameter----------------------- --------------Depth----------------------------------------------------Liquid Capacity------ --------------------gals. <br /> Privy: Distance from nearest wO------------------------------------------------Distance from nearest building.-----._______.._________-_____.______._ <br /> ❑ <br /> uilding--------------- ---------- -------------- <br /> El Distance to nearest lot line------------------------------------------------------------------------------ <br /> ---------------------- ------ -------------- <br /> R modeling d or repairing (descriibe): ill --------- ---- - <br /> - -­--------------- --------------- ----------t---------------- ------ -- ----------- <br /> 772i--- - ---11- - -------- ---------- <br /> - -------- ---- <br /> ---- ---- ---- ---- <br /> -- --------- -- ---- - --------- - <br /> -- --------- --- -------- - --- I- ___ - ,7 -- --::---------------------------------------------------------------------------- -------- <br /> r y r ify tha av prepared f s. P nation an fi"e work will be done in accordance with San Joaquin ounty <br /> ordinances, S laws, a les and re ions of the San Joaquin Local Health District. I <br /> (Signed)----- ------ y -- - -----------e-------------------------------------------------------------------------- -,-(,Owner andlo Contractor) <br /> --------------------------------------------------------------- <br /> By:-----------------_- - - --------- ----------------(Title).. ... . ....... -------------- <br /> ------ ---- <br /> a e on revers <br /> (Plot plan, showing sizeof lot, location of system in relation to wells, buildings, 0+c., can be pla e on revers idel. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �ti --------------------------------------------------- Z <br /> -------------- DATE--———--------------------------------------------------- <br /> REVIEWEDBY----------------------------- -- ---- -------------------------------------------------------------------------------- DATE__ <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------qr, - -------------------------------------------- <br /> Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------ --------------------------------- <br /> I <br /> ---------------------------------------------------�----I------------------------------------------­----------------I------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------ .......------------------------------------------------------------------- <br /> -----------------------------------------------;------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------- <br /> ---------------------I--------I------------------------------------------------- ---------- --- -------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION <br /> BY:----- ------ ------------- ------------- Date------------------------------------------ ------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2m Revised W-2100 <br />