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6- APPLICATION FOR SANITATION PERMIT Permit No.4A-.J-1 / <br /> + ielv (Complete in Duplicate) <br /> Date Issued ._-_ �- _f_.S 1/ <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 A ,OCATION-- ---- - � 4 I --------------- --- - -•--------------------------------------------------------------------- <br /> Owner's Name---------- - - • --- ----- ----------�-- - -- -------- Phone--- J------ _ <br /> Address - -----�- ---- ------- --•-- •------------- <br /> Contractor's Name----� '-----_------•• -----•------------------------ - Phone------------------------------ -- <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court %Motpl ❑ the, ❑ <br /> 77 Number of living units: _�_ umber of bedrooms ___� Number of baths __�S.f_ Lot size ___-_____________7--U-__________________________` <br /> Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 fee+: Sand Gravel Sandy Loam E] Clay Loam E] Clay E] Adobe 24ardpan E]Previous Application Made: Yes E] No VE]New Construction: Yes [ r"No ❑ Q <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic k- Distance from nearest weI <br /> - Dista of fro fou ation_________�/_____-Materi Lf________________________ 'u�X No. of com artments_______ ___________Size_ _X_9x47___Li uid de t ________________________Ca Capacity <br /> P q Jpr� P Y------ � 1 <br /> Dispos Field: Distance from nearest we ___________ istance fro foundation____------- ------Distance to nearest lolifv <br /> !J <br /> Cy�►' Number of lines_______ __ _ _____ __ L th of ach line_______________ Width of trench_____.____ <br /> Type of filter ma ria �D ,�--___ <br /> yy <br /> ------! ----------- - e of filter material------_r ___ Total length-------------I--!-- ------------------- <br /> Seepage Pit: Distance to near st well- --------------Distance from foundation-----------------_Distance to nearest lot line--____- -_____ <br /> ❑ Number of p-iits----------------------Lining material----------------------Size: Diameter------------------------Depth-----------------------------__-- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________.________-_-____-___-_ <br /> ❑ Size: Diameter--------------------------------------Depth.---------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well----------------------------_--------------------Distance from nearest building-----------------------------------._-___. <br /> ❑ Distance to nearest lotline--------------------------------------------------------------------------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------------------------------•----------------•---------- <br /> --------------------------------•------------------------------....--------------------------------------------------------------------------------- •----------•-------------------------------------------------------- <br /> ------------------------------------------------------------• -------------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules <br /> ° and regulations of the San Joaquin Local Health District. <br /> (Signed)----__ "?�. ��c s A,rt -------------------------------------- -- -----(!Owner nd/or Contractor) <br /> gr--------------------- ------40 ---------------------------------------------- - -- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY----------------------------------------------------------------------------------------------- DATE_-- ------------------------------------------------ <br /> REVIEWED BY------------------------------------- ------------ ----------------------------------------------------- DATE <br /> ------------------------------- <br /> BUILDING PERMIT ISSUED--------- --------- - ------------------------------------------------------------------------- DATE <br /> Alterations and/or recommendations_________________ _ ___ __ <br /> --•----•----------------------------------- ---------------------------­- -----------------------------------------------------------•-------------•---------------------­.-................------------------------------- <br /> ---------------------------------------------- --------------------------------------•--------------------------------------------------------------------------------------------•--•----------------------------•------- <br /> -----------------------•------------------------------------------------------------------------------------ ----------------- ---------------------------------------------------•--------------------------- <br /> --------------------------------------------------------------•------------------•---------•----------------------------•-•--------- ----------------------------:--•--------•----------------------- <br /> f � <br /> FINAL INSPECTION BY:------- i r---- ---------------------------------- Date------------- / 1 /'4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 11 <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />