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APPLICATION FOR SANITATION PERMIT Permit No. ------ <br /> (Complete in Duplicate) Date Issued 13--- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein dw' ribed, <br /> This application is made in compliance with C unty Ordinance No. 549. Z411— <br /> JOB ADDRESS AND LOATION -------- --- <br /> -----------P <br /> --------------------------------------- Phone---------- <br /> Owner's Name----------- ___ _. ) <br /> Address ...... - - ------- ------ ---------- - ----------- - ------------------------------------ <br /> Contractor's Name-----------------_----------- ----- -------------------------------------- ---------- - ---------------------- -- ---------- Phone------------------------ <br /> --------- <br /> Installation will serve: Residence Apart ert Hou'se"' <br /> EConmercial [ Trailer Court F <br /> Motel [I Other 0 <br /> Number of living units: ---I- Number of bedroomsr<Num6er of baths J--- Lot size ------ ------------------------------------ <br /> — A <br /> Water Supply: Public system E] Community system El 'Private A Depth to Water Table -#?Tt-.f�6 1 <br /> Character of soil to a depth of 3 feet: Sand E] Gravel Df, Sandy Loam El Clay Loam X Clay El Adobe E] Hardpan 0 <br /> Previous Application Made: Yes 0- No X Now Construction: Ye, <br /> TYPE OF INSTALLATION AND SPECT KICATIIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_____570.___DistanCfrOk foundatio,-------Lo-------M,te,i _------- ---------- ......I -A <br /> No. of compartments------.-_- -- ---------- ---LiquIld <br /> # -depil - --.--------Capacity-_•-0000 <br /> — <br /> Disposal Field: Distance from nearest Distance from foundation___A-4.._._..Distance to nearest lot line_07,W-_-W_1K <br /> lines_________ ....... _Z__A - � <br /> Is /------7------------ <br /> Number o ongth of each line---------TO--- ogtren�h__---- ;Type of filter material---311�. _ epfh of filter material-------I_t?t......Total lenth-------.57-6-----------I------------zl§� <br /> Seepage Pit: Distance to nearest well-----6-0--------Distance, fromAfpondl t' n- ......Dis?ane to nearest lot line----------------I <br /> Number of pits-------/-------------Lining maferjalljo�C4' G-- ---- -------- <br /> ----r---- <br /> from U <br /> u, <br /> Cesspool: Distance from nearest well-----------------Distance ndf ion----------------,__ Lini g material____..__-_____________--________._. <br /> Size: Diameter----------------------------------- Depth-------------------------- t ---- ------------Liquid-Capacify---------------------_!6­90ls <br /> Privy: Distance from nearest well______ ------------------------------------------Distance from nearest building----------------------------------------- <br /> Distanceto nearest lot line__.________________________ _ ---------------------------------------------------------------------------------I------- -- - <br /> f - ------- - -- ------------- <br /> t�_ *.�e <br /> Remodeling and/or rep firing d scribe}: ---------- <br /> ------------- - ------ -- --- <br /> --------------------------------------- --- ------------------------------------------------------------- -------------------------------- <br /> ------------------------------------------------------------------ <br /> -------- <br /> ------------------------- ---- ---- --I-------------------------------------------------------------------------- <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}------ AIL"aj------6.2-------1_ _,!----------------------------------------------- --------------------------(Owner and/or Co'n <br /> tractor) <br /> ....................................... <br /> By:----------------------------------------------------------------------------( -----------------------------------------------(Title) -----------l------------- <br /> (Plot 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 /> APPLICATIONACCEPTED BY------------------------------- ------ ---------------------------------------------- DATE------------------- <br /> DATE <br /> ATE-------------------- <br /> REVIEWED BY----------------------------------- - -------------- ---- Z ------------------ <br /> ---- ----- --- - <br /> --­--------------------- DATE q <br /> BUILDINGPERMIT ISSUED-------------------------- ------ ---------------------------------------- DATE_ --------------------------- - <br /> Alterationsand/or recommendations:.---------------- -------------------------- - --------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------- - --—------------- ------------------------------------------------------------------------------------------ ------------------------- <br /> ------------------------------------ -------- ---------------------------------------------------------------------------------- ---------------------------------------7------------- <br /> ------- ------- <br /> ------------------ ------- ---------------------------------------------------------------------------------------------------------------------------------------- -----­_­­ <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-11-2M 10-52 Revised W-2100 <br />