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- APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work h rein described. <br /> This application is made in compli anc eewit�y Ordinance No. 549. <br /> JOB ADDRESS AN CATION....._-._ �� n-- <br /> Owner's Name----- -----•------ ---- ----------- ------------------------------------- ----- Phone------------•-----------•- <br /> Address------------------ d_ ----------- ----- <br /> Contractor's Name-------- ;;<partment <br /> - - ------------------------------------------------------------------------------------ Phone--- ------ -------•---------•- <br /> Installation will serve: Residence House ❑ Commercial ❑ T iter Court E] Motel El Other F]Number of living units/-------- <br /> Number of bedrooms 2-_ Number of baths �-_.__ Lot size E3__c�'.k 1- __ ____________-__--._,._ <br /> Water Supply: Public system �ommunity system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeQ__10Tiardpan ❑ <br /> Previous Application Made: Yes ❑ No D,-<ew Construction: Yes Uk,<o ❑ FHA/VA: Yes ❑ No E4� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: t, _ <br /> (No septic tank or'cesspool permitted if blic sewer is available within 200 fleet.) J�E'/ .I� <br /> Septic nk: Distance from nearest well____ -.__Distance fr m fou dation.!-G._.__=:__.M e�ial._I/_ ____________________________._.____.__. <br /> No. of compartments__.__2'_-____._.__Size_. . ---Liquid depth___.?_____ _________Capacity_____ep)_a__. <br /> Disposal Field: Distance from neare well___�I/ "._Distance from foundation____�®.t_.__..Distance to nearestVo �pe_._�_-__--_S V_r Y5j�j of lines_____ __ Zjy_ _Length of each line_-_t_._ �_____)__________-Width n trench__ <br /> V Type of filter material_._ ____-___---___Depth of filter materia �'/____.___..-_Total length.___ � ________________._____ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material---------_-------------Size: Diameter.--------.-------------Depth--------------------------------- W <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- \/N <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 /> -------- - <br /> --- -------------------------- --- -------------- ------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------- ------- ----------------------------------------------------- - <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> Q ........4 <br /> Signed).. . <br /> . ------ --- ---.---_---------------------------(Owner and/or Contractor) <br /> BY: s�--------------------- ------------------------------------------------------------------.--.-(Title)------------------------------------------- ----------- - <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 /> APPLICATION ACCEPTED BY----------------- ----- --------------------------------------------------------.-- DATE----------------------------- <br /> REVIEWEDBY------------------------------------------------ -- --- ----- -------------------------------------------- DATE------------------ <br /> BUILDING PERMIT ISSUED----------------------- ----------------------- ------ DATE... ---------------------•----------- <br /> Alterations and/or recommendations:_____ -_ r <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-9-2M Revised 1-57 F,RCO. <br />