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APPLICATION FOR SANITATION PERMIT Permit No. _..,F .4_. <br /> u (+ (Complete in Duplicate) <br /> Date Issued --- <br /> Applica;ion 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 Ordin a No. 549. <br /> JOB ADDRESS AND CATION � -- ----- ....- -- • -Owner's Name•. - ---•- Phone.................................. <br /> 67 <br /> Address---------------•-•-- �� --------•--------- ------------------------------------------------------------- /-- <br /> Contractor's Name................................ - ---------- -----------------------------------------------------------------------•------ Phone,!! <br /> Installation will serve: Residence 12__� partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other❑ <br /> Number of living units: _ ___ Number of bedrooms sZ Number of baths Z. Lot size _________________••- <br /> Water Supply: Public system ❑ Community system ❑ Private M-t_�e'pth to Water Table S74 ft. <br /> Character of soil to a,depth,of 3 feet: Sand ❑ Grave!.❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No a---New Construction: Yes 0 No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> VDistance from nearest well-----------------Distance from foundation....................Material-•--__-_-__-___-__-_______--•-----_-.-______-__. <br /> No. of compartments--------------------------Size................................Liquid depth--------------------------Capacity....................... <br /> al ie�l Distance from nearest well-----------------Distance from foundation.-_____-__--__----Distance to nearest lot line................. <br /> Number of lines-----------------------------------Length of each line..............................Width of trench-.----_--_-_.-__-_-_-.__--___-_.-- <br /> Type of filter material--._. ------ -------Depth of filter material----------------------- length.......................................... <br /> Seepag i : Distance to nearest well/ ---_-___Dista m ndation_Z ... Distance stance to nearest lot line_zd-_�__ <br /> Number of pits....._-__---_____Lining materia :.Size: Diameter__!; ..........Depth_-_a1,.5 7.................. \ <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 lot line----------------------------------------------------------------------------------------•---------------------•------------------------------- <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 r, anrules and re lations of the:San Joaquin Local Health District. <br /> Si ned --------- ---•-•-- .....................--- -- - --- • ner and or Contractor <br /> By: / ?1a ------(Title)--- ............B .. i �--! <br /> (Plot plan, showing size of lot, location of system in i o wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------------ -------------------------------------------------------- <br /> ----------------------------------------------------- DATE-----e--•--- <br /> REVIEWEDBY------------------------------------------ ---- ------- ----------------------------------------------------------- DATE------ <br /> BUILDING PERMIT ISSUED....................................• ....... DATE----------- ............ <br /> Alterations and/or recommendations: -------------------------------- <br /> ••............... •------ <br /> G-�e . �► --- --- - ------------------------------------ <br /> ----------•---------------------------------•-------------------------------•----....------------------------------------------------ ._....-----•--......-••--•--•••---•---------•------------•--•----•----•••--•••--..... <br /> ------------------------------------------------,....................................... .................................... -------------------......------......------------------------------------------.----------•••-- <br /> FINAL INSPECTION BY:----'�-------------------------------------- Dater----- � <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 /> kL ES-9-2TGf';-,,. Revised W-2100 <br />