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APPLICATION FOR SANITATION PERMIT Permit <br /> (Complete in in Duplicate) f j <br /> -Date Issued <br /> 0 '15 " 4' <br /> 111/ <br /> Application is hereby made to the San Joaquin Local Health District for a per to cops- <br /> o s+ruct and inst6ll the work herein described. <br /> This application is made in compliance with County Ordinance No. 519. U&_0-9 1 /0 IA ...-,- <br /> «: At; V A 1E Q <br /> JOB ADDRESS AND LOCA ION------------------ ��`�-�` /_ 1- LA > a� cC J - "c - y <br /> t - ----- ---------------------------------- - ------------------ <br /> - - -------- -- <br /> Owner's Name---------------------------------------L --- �----- JZ�.�,�f, �------------------------------------- Phone__-- ------ <br /> Address ------------ ,_- ;-------------------- -------- <br /> ....�,-•----------------------------------------------------------------------...... <br /> X- ' �. <br /> Contractor's Name---------------------------- � � <br /> l _ ±a- '�" _` � ` .I <br /> ----- Phone l�� <br /> Installation will serve: Residence b' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ a <br /> Number of living units: -__ Number of bedrooms 0__ Number of baths _j_'_-Lo+ size -_n?-4_�'-p___________________________.___-_ <br /> Water Supply: Public system ❑ Community system ❑ Private IV Depth to Water Tablec>?J ft. <br /> Character of soil to a depth of 3 feet: Sand [ Gravel ❑ Sandy Loam ❑ Clay Loam bw Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ZW New Construction: Yes ❑ No ❑,5�'t,04. J4 :y ' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: r] F <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-AP D ____ <br /> _ Distan jfrom foundation---1-57-------•------.Material--- ---•---------------- <br /> No. of compartments- .2--------- <br /> - _-----Size- N <br /> Liquid depth---frcr,�_--_------Capacity__ ,Cnc <br /> Disposal Field: 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 /> i �^r ~- s <br /> Seepage Pit: Distance to nearest well_�_Q_0_ _____--- <br /> Dista �rom <br /> dation---1_U---_.._____.Distance to nearest lot line______.___.. <br /> Number of pits-__________________Lining materi ____------ Diameter__,3"11 ___.Depth__.-- *r :2-_• <br /> Cesspool: Distance from nearest well-----------------Distance t foundation_-.-_-_---------__..Lining material---------------- <br /> ----__-________..____. <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--____________-__-_-_-___________________. <br /> ❑ Distance to nearest lot line <br /> Re eling and/or repair-n (describe):-------------- <br /> --------------- <br /> " r` r. --•�_ �^ °'� r"` "` t1 , <br /> --------------------- <br /> ------------- <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, anal-rules and regulations of the San Jaa vin Local Health District. <br /> (Signed) =' 1 --- ---- ----------- '- e-r--"-- r�.�..- Contractor) <br /> By: -: - ` ------------------------------------------------------------ ;--�--------------- <br /> (Plot plan„showying size of lot, location of system in relation to wells, buildings, etc., can be plaed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-�-- ----- --------------------------------------------------------------------- DATE e----------------------------------------------•---- �. <br /> REVIEWED BY DATE-----� -------------- ' <br /> --------- - <br /> ------------------------------- <br /> BUILDING PERMIT ISSUED------------- - ------------------------------------------------------------------------------ DATE--------- --- <br /> Alterations and/or recommendations------------------------------------ ------------------------------------------------------------------------ <br /> ------------------------- ------------------------------------------- ------ -----------------------------------------------------------------------------------------•----------------------------------------•------------- <br /> -------------­-------------------------------------- ---------------- ---------------------------------•-----------------------------------------------------------------------------------------------•------------------- <br /> ------------------------------------------------- <br /> - . <br /> ----------- -------- ----- <br /> Z1. <br /> FINAL INSPECTION BY: •_ ------ --- ----- Date --- -------- ---- ---- -- -- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreet <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />