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A/ APPLICATION FOR SANITATION PERMIT Permit No. ..` /2`�, <br /> (Complete in Duplicate) Date Issuedli D� <br /> t.�. <br /> Application 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 /> JOB ADDRESS AND LOCATION.---------------=----------- ---------- ---------- -- -- --- .......---------------------------------------------------------- <br /> Owner's <br /> - - - - - -' -- <br /> Owner's Name---------------------------------------------` ------------------------------ ---------. ........_..._.._._._. Phone,................................... <br /> Address----------------------------------- ............................... <br /> Contractor's Name--------:.............-:-`..........----------------------------------_._._..._._._..._----------------------------------------- Phone-................................ <br /> Installation will serve: Residence dApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: _1..._. Number of bedrooms ..r'.:.. *V{,ber of baths Lot size .:---.-----------------._......------.._----._........._ <br /> Water Supply: Public system ❑ Community system ❑ private [Er[El' Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[3_,Hardpan❑ <br /> Previous Application Made: Yes ❑ No []rf( New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No L—.d"�" <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic,Tank: Distance from nearest welk_ ._:,.✓.---:....Distance from foundation. --.. '.:......Material------____...._..._...__-......:_.._;...... <br /> Q No. of compartments_._._._CI----------Size........---------------------Liquid depth-_---------------_--.--Capacity.....----._- ,...-. <br /> Disposal Field: Distance from nearest well. .._..Distance from foundation __...Distance to nearest lot line..:_.:.......:.. <br /> Number of lines------ .._..___.77t7.�_._Length of each line.................__---.......Width of trench.__....._.�__.._.._.--------- <br /> Type of filter material::' ._.`_.:-.::Depth of filter material :_';..........Total length.......... �'T...•�"_ �;;` <br /> Seepage Pit: Distance to nearest wall------t��.. .0_y.__Distance,f�om foundation......1.0.....Distanfe to nearest lot line......i�...... <br /> Number of pits----------/-------.Lining matarieL // 0 .4 _ . 51 _.Depth..._....Zs.............. <br /> Cesspool: Distance from nearest well.----------------Distance from foundation-----.----------._..Lining material...... <br /> ❑ Size: Diameter--------------------------------------Dept h....----- ------`--------------------------....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 /> x':--------...._...._.._--"---------------------------..........-..........._................--...........'---------.----------------'------- <br /> yV_ w. <br /> .s-F:: ,.r - �."IC F�.,.-.4',i.,.....tnf�- :... .i -f'..^!CC. .:._..... -- >. ---- <br /> I hereby certify that I have prepared this application and that the wdrk 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)._..".'.....-- '= �--'-_._...._r.s,.-_. ---------------._-----------------------------------..............(Owner and/or Contractor) <br /> By:-------`-----'.......... -- ----------'--------------------------------------------..-- -'--... ..(Ti+le)-------------------`-"----------------..------------- <br /> (Plo+ 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 w ..................................... <br /> - - - <br /> REVIEWED BY.........................­.- <br /> ----..-'-----------------------------------'-----------------1-'._... DATE P-------•-----------------------•----•------ <br /> BUILDING PERMIT ISSUED..._.... 'J' --- -- . .......----------------------------------------------- DATE---st:ti -- ............................ <br /> Alterations and/or recommendations:_......_._._..._..................................................... <br /> ..... -- --- - ' ---------' -----------._...... .... <br /> Jp ---._-_.....---- <br /> ..... «..-'---'- –'-- <br /> ......------------------------------------ <br /> --- ... .. ... . ' I. y.. ....... ..A .... .. ....... <br /> ----------- - - -- ---------- ....----- '- ..._._....---......-- .._..........._... <br /> FINAL INSPECTION BY:.--------- -- of l---------------------- Date----------- --- ------------------ ------ <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M . Revises 1 57 EP.CO. <br />