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APPLICATION FOR SANITATION PERMIT Permit No. <br /> f (Complete in Duplicate) 7/ <br /> 4 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 No. 549. <br /> f <br /> JOBADDRESS AND LOCATION... --�-� ------------- !_.a_.0------`/-------------------------------------------------------------------------- <br /> nn <br /> Owner's Name ,C.�U- o.1116- <br /> LL ------ Phone------------------------••----- <br /> VO <br /> Address_.._..., ~'��--------------/---------- ------- ------------------------'------ ----•-------••-•--- ...... <br /> •--------------- <br /> •-------_----------------------------- <br /> ---•------- <br /> Contractor's Name------�---7'----- i4? �- -----f----Com-----�--=---------- --------•----------••--- phone s?_- r!a Q <br /> Installation will serve: Residence 1] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ N <br /> Number of living units: _./_-_ Number of bedrooms . -- Number of baths .-J___ Lot size _______�;_- --------------------------- <br /> Water Supply: Public 'system '® Community system ❑ Private ❑ Depth to Water Table _,P-'Z�_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [B Hardpan E] I <br /> Previous Application Made- Yes ❑ No X New Construction: Yes ❑ No LN <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: istance from nearest well-----------------Distance from foundation--------------------Material_______-___----___:----- ----------------------- <br /> Xo. of compartments---------•----------------Size----------------------=---------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field:r Distance from nearest well__--_____-_____.Distance from foundation--------------------Distance to nearest lot line----------------- <br /> ® Vumber of lines-----------------------------------Length of each line-:----------------------t-----Width of trench----------------------------------- <br /> Type of filter material-------------------------Depth of filter material-_-_--____--_____--_Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well-----A1d_JVAT_-_Distance from foupdation------2`'_____"Distance to nearest lot line------ <br /> D � <br /> Ix Number of pits_-_-__.1______________Lining material-- e_�f�'a ize: Diameter___ -___________ epth--.- __�_____________-___ <br /> Cesspool: Distance from nearest well-----------_-----Distance from foundation---------------------Lining material_-____-____-_-__________-_____-_-___. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------- ------------------Liqui.d Capacity----------------------------gals. i <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 /> ----------------------------------------------------••-------------•--------------•-----------.----------------•---------•-------. .--•---••-----...------------------------------------•-••--------•--•--••---------------- <br /> -.hereby certify f4at l have prepared this application and that the work will be done in accordance with San.Joaquin County x <br /> ordinances, State s and rules and regulations of the San Joaquin Local Health District. r. <br /> ___Owner and/or Contractor <br /> (Signed) -- -------------------------------------------- <br /> BY� ! '± �! f --------- ___ -------- --------------------------------------------(Title)---------- _)a--------------------------------------- <br /> B <br /> plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ----- ------- -s- ---------------------------------------------------------- DATE------ -7 ------------------------------------------- <br /> REVIEWEDBY--------------------------------------------------- - ----- -- ---------------------------------------------------------• DATE ---- ----- ---------------------------•----------- <br /> BUILDING PERMIT ISSUED--------------------------------- ---- --- - ----- DATE- ---- ---- ----------.--------------------------------- <br /> Alterations and/or recommendations:--------------------------- - ------------------------------------ ---- -.S:--- <br /> ----------------------------------------------•--------•----------------- ----------------------------------------------------------------------------------­------------------------------------- ------------------------ <br /> -----------­ ---------- - <br /> FINALINSPECTION -BY: .............­­--------------- ------------•------ Date---- _- L--------------- ------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> �S <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />