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1� APPLICATION FOR SANITATION PERMIT Permit No.5. J7_._....____ <br /> (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 Ordinance Na. 5f9. <br /> A, , } <br /> JOB ADDRESS AND LOCATION....._.. \ / ----------- <br /> Owner's Name-------------------•---------- [ --------- ------------ Phone-4- 27-Z7. <br /> Address-------------------------------------------------. .J - ------------------- <br /> Contractor's Name-----`----------------------- !_ - - ----------- ------- -----. <br /> Installation will serve: Residence 2 partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __I-- Number of bedrooms .1-'Number of baths -1__ Lot size __-_/- _ ��_v._._ <br /> - - - ---------------- <br /> Water"Supply: Public system ❑ Community system ❑ Private ❑-15e—pth to Water Table <br /> Character of soil to a depth of 3 feet: Sand FGravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe lardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑ . � \ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: , <br /> (No septic tank or cesspool permitted if.public sewer is available within 200 feet.) <br /> eptic T Distance from nearest well.................Distance from foundation-------------------Material___--_-_-__-_-_______---_-_-___---.-_--------- <br /> No. of compartments---------------------------Size--------------------------------------------- Liquid depth--------------------------Capacity-=-•--------•------•--- <br /> os l 1 Distance from nearest well_--_---- _'._.Distance from foundation_—n---_`--_--_-.-.Distance to nearest lot line_________________ <br /> Number of lines---------------------------------Length of each line__l -------_-----------.Width of trench------------------------------------ <br /> Ty <br /> --.__---_.-_:--_---_-----.-____--- <br /> F Type of filter material-------------------------Depth of filter material----------------------Total length------------------------------------------ <br /> p ,,��� <br /> Number of pits_I_,l_ __ .. -------- g •_..Size: D�titer_.Distance to nearest lot line__/Q-_f____ <br /> Seepage Pit: Distance to nearest'well -..0---__ <br /> Linin mDteraalce fr f undation-•-•----- --- 11 Depth--,cr--�---------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation....----------"----Lining material--..--_-.______--_-___.---_--__-___. <br /> Size: Diameter--r-----}-------------- - ---------De th-------,--y'•------------------------=---------------Liquid Capacity --------gals. R <br /> Privy: Distance from nearest yell_-:_._-" :�""___ :... ..........Distance'from nearest'building_-_'_--_-_--.-_---__-__..._--.-----_..._. + <br /> ❑ Distance to nearest lot line - ----------= = •---•-=----•----••----------------------------------------------------------- <br /> Remodelingand/or repairing (describe):--------- ----------------------------------=-------------•=•-----------------------•-----•-------------------------------------------------------------- <br /> --•--•-•------------------------•----•----•---------------------•------•-------------------------------•-----•-------------------------- -•------------------------------------------------------------------------- <br /> --•-----..----------------------­------------------- '---------------------------------------------•---•--------------------------------=---.---- <br /> ------------- ------•-----------------•-------------------- -•-------------------------- -----------•-------------------------------------------•-------•---•------------------------------ <br /> 1:hereby tify that 1-have .prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, S ate laws, and rules and regulations of the San Joaquin Local Health District. <br /> [Signed)..... �--- ---�--- �--------- - -------- - ----------------------- _-C------ rvf"�-or Contractor) <br /> r------------------ <br /> B Title v-- --------------- <br /> -------------------------------------------•------------------------------ ---- -- [ ): <br /> (Plot plan, showing size of lot, location of system injelation to wells, b ' Ings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- DATE.--• = <br /> REVIEWED BY------------------ - DATE <br /> ------------------------------------------- <br /> BUILDING PERMIT ISSUED.--•-----------------------------�`Zl. •----`-- ------ DATE..------------- --------------•--------------•------ <br /> Alterationsand/or.recommendations:--------------- ---------------------------------------•------...----------------------------•---------------`*1 ---------•-------_----------. <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 Revised W-2100 <br />