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APPLICATION FOR SANITATION PERMIT <br />(Complete in Duplicate) <br />Permit NK� <br />Date lssue -/ <br />gA <br />plica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br />This <br />application is made in compliance with County Ordinance No. 549. <br />JOB ADDRESS AND LOCATIONJ,� - &4 - <br />_---------- ------------------------------------------------ <br />Owner's Name ------ t -- -------- ------------ ---------------------------------------------------------------------------- Phone ------------------------------------ <br />Address------------- -------- -------------------------------------- <br />Contractor's Name _0 --- ---- ----------- --------------------------------------------------------------- ------------- ------- PhoneZTI-�-_--6 <br />---- ----- --------- <br />,Me x <br />----------- ----------- <br />Installation will serve: Residence 6--A—partment House E] "Commercial 0 Trailer Court [] Motel El Other E] <br />Number of living units: i/ ----- Number of bedrooms L Number of baths _/---- Lot sizeV ------ X .... I --- J—t> ------------------- <br />Water Supply. Public system k/Community system [-] Private F] Depth to Water Table 3 ft. <br />Character of soil to a depth of 3 feet: Sand E] Gravel E-] Sandy Loam El Clay Loam El Clay [:] Adobe Hardpan ❑ <br />Previous Application Made: Yes E] j No F] New Construction: Yes F-1 No ❑ <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br />Septic, Tank: Distance from nearest' well_________________ Distance from foundation -------------------- Material --------------------------------- <br />-------------- <br />No. of compartmenfs --------------------- .-.--Size -------------------------------- Liquid depth-------------- - I ---------Capacity----------------------- <br />tsposal Field: Distance from n6arest. well--___...._.___._ Distance from foundation -------------------- Distance to nearest lot 'line_______-_________ <br />''� - Number <br />ine----------------- <br />Number of lines1-------------------- -------- :!iLength,of each line--= _----------- Width of trench----------------------------------- <br />Type <br />rench---------------------------------- <br />Type of filter m C 'ferial ------------------------ kDepfh of filter material ----------------------- Total length__------------------- -------------- <br />F <br />Seepage Pit: Distance fo.nearestogn a ion ---- <br />------ <br />Distance rom f d ti -------- Distance to nearest lot line ---- <br />Number of pits -------- I ----------- Lining r�ateria;__k---- ----Size: D ' iameter ---- 3_3 ----------- Depth ------•4--4 - — ----- <br />Cesspool: Distance from nearest well_________________ sfance from founda.4fion ... ------- ------- Lining material_____ ---..__________._________.______.q <br />- Size: Diameter -I j ----------.Depth--------------------------------------------------Liquid4- <br />Capacity----------------------------gals- <br />Privy: <br />apacity----------------------------gals,Privy: <br />Distance from nearest well ------------------------------------------------Distance fr.64,07"e'aresf building--______.___------____________--__-___. <br />❑ <br />uilding----------------------------------------- <br />171 Distance to nearest lot line- -- --------------- ----------------------------------------- <br />------------------------------------------------------------------ <br />i <br />Remodeling and/or repairing [describe):----------------------------------------------------------------------------- ------------- ---------------------------------- <br />------------------------------- ­ ----------- ------------- ---------- ------------------- - ------------------------------ ---------------------------------------- ------------------------------------------------- <br />I it <br />------------------------------------------------------------------------------------------- ------------------------------------------------------- --- <br />I------------------------------------------------------------ : ------------------------ ­ ---------------------------------------------------------------------------------------- <br />I hereby certify that I have prep'ared fhis'applicafion and that the work will be done in accordance with San Joaquin County <br />ordinances, �eaws, nd rules rgu <br />l tions oft San -Joaquin Local Health District. <br />(Signed) ........ ----------- - -- - --- -- ----- --- <br />e— ontractor) <br />By:--------- ... ...---------------------(Tifle - <br />--------------------- ---------------- <br />(Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY ---------- I ---------- ------- ..... ---------- ------ --------- --------------- DATE --- <br />---------------- <br />REVIEWEDBY------------------------------------- � ----------------------------------------------------- ------------------ DATE ---- <br />BUILDING PERMIT ISSUED ------------- 1k <br />------------- ---------- -------------------- ----------------------- DATE. ------------------------ — -------------------- <br />----------------- ------ <br />Alterations and/or recommendsfions.l <br />------------ - ---------- - --------------------------------------------------------------- _ -------------------_-------- ----------- ------------•-------- <br />I <br />-----------_------- <br />t--------------------------------------------------------- ------------------------------------------------- ---------------------------------- ­ -------------- <br />---------------------------------------------------- I ------------------------------------------------------------------------------------------------------ ­ ---------------------------------- -------------------- <br />--------------------------------------------------------------- I ------------ ­ ------------------------------------------------------------------------- ­ ---------------------------------- - -------------------------------- <br />-------------------------- -------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------ -------- <br />FINALINSPECTION BY:--- 5-------------------------------- Date------/---------- ----- Z-`--- ---- --- ------ ----------------------------- <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 ; . Revised W-21DO <br />