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APPLICATION FOR S SANITATION PERMIT - <br /> Permit No. _____ <br /> (Complete in Duplicate) Date Issue �j <br /> • ll/ _. � <br /> ill�ispapplicafion <br /> lica}ion is hereby made to the Sari Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is made in compliance with County Ordinance No. 549. <br /> �,.. <br /> JOBADDRESS AND LOCATiBN------I------------- ---•-�---/-- --------- --------------- <br /> M ; <br /> -------------------------------------- <br /> /1111 � -------- ----------- --... -------------------------------- - <br /> Owner's <br /> Name - ---- ----------i----------------••------•-•-------------------------------- -----t--4-•--=- ---------------- Pone <br /> • 6 t E <br /> Address•--_----- ... 7 I � <br /> Contractor's Name. =_ =j e'-s'��' Phone- --/---�---- -� � <br /> Installation will serve: Residence artment House ❑ Commercial ❑ railer Court ❑ Motel ❑ Other ❑ <br /> Number of living unitsi4_l___ Nu of bedrooms __-_--. Number of baths .1_:_ Lot size ____� 1� <br /> 5 - ------------•--------•- <br /> Water Supply: Public system [B--Community system ❑ Private ❑ Depth po'Wafer Table <br /> -- _ <br /> Character of soil to a depth of 3 fe'efl S6 nd F1Gravel E] Sanndy Loam ElC�Iay,Loam ❑ Clay E] Adobe ardpan r] <br /> Previous Application Made: Yes ❑ No rg�-' New Construction:JYes ❑ No L4l <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: " , <br /> _ <br /> (No septic tank or cesspool permitted if'public sewerawithin 200 feet.)s-available <br /> Septic Tek: Distance from nearest-weell-��Dista��from foundation-_ _ __________Material__-______�______'___________-_�.___ <br /> 0/ No. of compartments-- --- -------------Size.----------- - -•---Liquid depth------��-y---------Capacity-` `5--d--- - -- <br /> �i <br /> Disposal Field: Distance from nearest well_ ' L.._D stance from i oundafion__;3_-d_._.__..Distance to nearest lot line__3____________ <br /> 02 � Qi <br /> Number of lines------- ---------------------------Length of each line_-_-_-----------------------Width of trench--_---�--V-------------------- <br /> Type or filfer materiai___J' /�a _-Depth of filte material-__ _��_____.__Total length-__-_-_-1_ o----_________________ <br /> 1_ _ <br /> il <br /> Seepage Pit: Distance to nearest well____________ ___ __Distance from foundation4___--_-___-____....Distance to nearest lot line_______.__.__.__ <br /> El Number of pifs----------------------Lining material-----------------------Size: Diameter------------------------Dept'n---------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---..---------------Lining material------------------------------____.._. <br /> ❑' Size: Diameter-------------------------- -- - ----Depth-----------------------------------------------=----Liquid Capacity-----------------------------gals. <br /> . <br /> Privy: Distance from nearest Weil--------------------------------------------_.__Distance from nearest building--------------------------------------------- <br /> ❑ Distance to nearest lot line--------- ----------------------------------------------------------- ---------------------------- ---------------------------------------- <br /> Remodeling and/or repairing (describe):____ '-------f---- - -- --- <br /> n ---------------------------------------------- ----------•-----------------------•---------------•--------------------------- <br /> 71 - <br /> ----- <br /> --- -------- ------------- ----- �"-------------------•---------•----------- = <br /> --------------•-------------------------------------------­­---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I <br /> •-------------------------------------•--------------------------------------------=----------------------------------------------------------------------------- <br /> I hereby certify that I have prep`ared,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 /> i � F <br /> )(Si - wne oCtractor <br /> gned) -----= --------------------------- -------- r on <br /> By:------------------------ ..---- - x . - -== (Title <br /> ) <br /> (Plot plan, showing size of lot, location of systemm i relation_•Fo wells, buildings, etc., can be placed on reverse side). <br /> jL <br /> r FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY -----------------------•--- ------ DATE----- --- r ! "'1 ----------------- <br /> y - . <br /> REVIEWED BY----------------------------------------- = DATE <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE-------------------------------------------------------------- <br /> Alterations and/or rejcommendafii] ;Ze----- <br /> ons-------------------------- w .ate^/"F ---•• -----------=-�y =---------------------------- <br /> ---------------------- <br /> - -- -- - - --- - -- ----------------------- <br /> FINAL INSPECTION BY:---------- ----- 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 Tracy, California <br /> ES-9-2M Revises! W-2100 �j <br />