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APPLICATION FOR SANITATION PERMIT Permit No. .-. -'` �.�3�---- <br /> (Complete in Duplicate) Date Issued <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 AND LOCATION----- ---------•--------------------------------------------- <br /> Owner's Name---- )1_ - -�_'' _ -- -; :� phone <br /> Address---C l k" -------- ------------- ------------------------------ <br /> Contractor's Name--- - - - -- ----•--•-----------------------------------------------—-------------------------------------------•----- Phone----••----------------------------- <br /> .�.t 4 <br /> Installation will serve: Residence [Apartment House ❑ Commercial's°], Trailer Court ❑l Motel ❑ Other ❑ <br /> Number of living units: __I---- Number of bedrooms __L__ Nurnbeart of baths _-L____ Lot size ___--3___________________________________________.__._ <br /> Water Supply: Public system ❑ `Community system ❑ Private Depth to Water Table . ------ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel.E]_Sandy-Loam°.❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application'Made: Yes ❑ No ElNew Construction: Yes e No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS' <br /> No septic +ank or cesspool permitted if 'ublic`sewer is available witAin 200 feet.) <br /> [ P P P PQ `k., �:4 t I �} <br /> Septi Tank: Distance from nearest well___J�-_��____Distance,fro fau dation�4�-_______.Materi !___ __________ _`----- --_---.-----. <br /> � <br /> Caaci#No. of compartments-____.-_ y_�______ ze__ _ <br /> i + f b r / 5- <br /> N. <br /> V <br /> Disposal Field: Distance from nearest well.. d____.u_,Distance-from'foundation_____ ______________Distance-to nearest lot h-�_____._.__. <br /> , / r <br /> N.umber of lines-------J_71--A---4---'_ILength of each line_______________________ Width of trench-------_-_-_ ___-__-___________-- <br /> 1D.e th of filter ma terial____.____1e Total len th__F <br /> " hype or filter material_,SY� __ _ __ ' p <br /> -------------- <br /> Seepage Pit: Distance to nearest well_________________ ____D.istance from foundation-------------.......Distance to nearest lot line______-_________ { <br /> [] Number of pits----------------------Lining #erial-----------------------Size: Diameter-----------------------Depth----------------------------41�s. <br /> 1 <br /> t s <br /> Cesspool: Distance from nearest well---'_"•:_____J'Distance from foundation--------------------Linin material_____-___________________-._-._ <br /> ❑ --------- � - -- ----------------------------------------------------- -- ----� .�Size: Diameter ;' iDepth ---- _-_- -- _ Liquid Capacity _ .__g..Privy: Distance from'nearest veli_____._.__. ___ Distance from nearesr building-.;____�_ _____________ __ __bistance to nearest lot line-------- ----------------------------------------------------------------------- ---------------------------------------- -------------Remodeling and/or'epairing (describe)-------------------------------------------------------------------------------- ---------------- ------------------------------•----•------------- <br /> f <br /> I------------------------­-­-,----------------------------------------------------------------- ------------------------ -------------------------------------- <br /> - ---------------•------------------•--------------------------------------------------------.-------------------------------------------- <br /> I hereby certify That I have prepared this application and +hat 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 /> (Signed)_ ------------- -------- ------------- ----------------------- --------------- -------- --- <br /> [O ner and/or Contractor) <br /> ------- ------- ---------- <br /> rBY:--------- --•-- ------- --------------------------------------------_------------------------------------------- -----(Title)--------- ----------- ---•--------------- - - ----------- <br /> l (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can Qbe,placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------- _ - ___- DATE____________ ___ <br /> ------------------------------------------------------------------- <br /> REVIEWED BY-------------i----------- DATE------------------ - <br /> ----------------------------- <br /> BUILDING PERMIT ISSUED---------- ---------------------------------------------•------ ----------------------------------------D----A----T--E--------------------------------------- <br /> ------- ------- --------------------------------- <br /> Altergtins and r re 'gym endatio,s---------- ------- --- •----- <br /> [[ / <br /> hTl( - 1 6 1 <br /> �S-nc ' -- -------- -- <br /> - <br /> -- - - . <br /> - ------ ------ --------------------------- <br /> -------------------------- - -- <br /> ----------- <br /> I --- --- ----- <br /> = - v <br /> ------------------- --------------- --Tj;� - --- ---- <br /> _ _�..+:—..�: _ s. •.wi.._rr�®.rte .ae�+ _ � ___._ <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 10-52 Revised W-2100 <br />