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APPLICATION FOR SANITATION PERMIT Permit No. ___��,__ •_:..__ <br /> [Complete in Duplicate) l <br /> Date Issued .... <br /> Applica}ion is hereby made to the San Joaquin Local Health District for a permit + construe and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 544. <br /> r ♦ k ; <br /> JOB ADDRESS AND LOCATION____ . - ___ _ ___._____ __....__ ----.-____ <br /> Ax---------------------- ----------------------------------------f <br /> .. PhoneOwner's Name---- 00"I <br /> Address -Contractor's Name--'---- ---- ------- ------ -- ----- ---------------------- <br /> Phonef- -- !!llo_I--fir <br /> Installs+ion will serve: Residence 3rtment House L] Commercial F1 Trailer Court E) Motel E] Other E] <br /> Number of living units: __ ___ Number of bedrooms __Number of baths -_ ____ Lot size .__Q___ . -- -k---f-LO_____________ <br /> Water Supply: Public.system` ommunity system F1F13 <br /> Private Depth to Water'Table .4_ ft. <br /> Character of soil to a depth of 3 feet*_Sand ❑j Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [I Adobe hardpan ❑ <br /> Previous Application Made:_Yes ❑ No A­�--New Construction: Yes �a ❑ <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____/__90---__.Material----_ __ _ ___ ___ ___ ________ __ ------- <br /> No. of�ornpartments_____, _Size__ ,S_� ,4-W-0_.___Liquid depth__��/ 11-________Capacity____. ____ <br /> Disposal Field: Distabnee from nearest weil_�2^!,t� - Distance from foundation___- _ ` /` <br /> p ��-....._.Distance to nearest lot line___ ___________ <br /> of lines------------ �p 'Length of each line-----2.,r---------------Width of trench---2 Y___•_--------------_-.--- <br /> AType of filter material__/_-A.___f`'____�__Depth of filter material___---1-4?....__.__Total length___._ _______________________________ <br /> Seepage Pit Distance,to,nearest .Distanceomt foundation-___ ; ..___.Distance to nearest lot line__/.�_____-__ <br /> Number of pits----___: Lining material--- _ -Size: Diameter_ <br /> Cesspool: Distance from nearest well_________________Distance from foundation-----___------------Lining material_____-______________-______'________ <br /> ❑ Size: Diameter---------------------------- -------i Depth_'- --------- -------------------------------------Liquid Capacity-----------------------------gals, <br /> Privy:: Distance from nearest well.......-------------------------------------_.-Distance from nearest building-------_"_-____________________________-_. , <br /> ❑ Distance to nearest lot line------------------------------------------- - --------- '. <br /> r f <br /> Remodeling and/or repairing (describe):---------------- -----------•------------------------ -------------------• --- '---------- ------------------------------------•-----••........... <br /> ------------------------------------•------------------------------------------•---•- •-------•-------------------------------------------- --------------------- ----------------------------------------- <br /> ----------------------------------••----------------------••----------•-------•-•-------------------••--------•--•------------------------------------ <br /> I 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 and regulations of the San Joaquin Local Health District. <br /> (Signed) <br /> B :------- - -- - •--- (Title)- C, ' <br /> Y -- ----w-- ) <br /> (Plot plan, showing size of lot, Iota+ion of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> Y <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ �f-- - ----------------------------------- DATE----------------;lL__--;2--- ----'`U------------- <br /> REVIEWED BY---------------------------------------------------------------------- :---------------•-•-•-•--------- ---__ DATE--------------------._...-------• - <br /> - ---------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------- --•------ <br /> Alterationsand/or recommendations:--------•--------------------------------------------------- =-------=------------=--------------------------------------------------------------•s-- ------------------------------------ <br /> .............. e- — <br /> --- ----------•-•--•----------•-----•-----------------------------------------------------------------_--------------------------------.----------------------------------------- <br /> -----•---------------------------------------•------_------------------------------------------------------------ ----------------------------- <br /> { <br /> � <br /> ---------------------------------------`--------- -•-----------,-----•------ -----------`-------------..--------- -------------------------------- <br /> T -•------------------- -- I----- -- <br /> FINAL INSPECTION BY:----------: n' '�-��-��----��-=-------- = --- ---------- Date---- �--- - •- -• -�-- -•--------------------------------------- <br /> SAN <br /> - - .... <br /> ----------------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Sfraet 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; . Revised W-2100 <br />