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Y <br /> APPLICATION FOR SANITATION PERMIT Permit <br /> (Complete in Duplicate) <br /> Date Issued�Q_-_�._�.�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 Couqiy Ordinance.No. 5 9. <br /> JOB ADDRESS A L CATION_____._ r <br /> n <br /> Owner's Name__ - l` _ '-� ------- - Phone !/ 74 <br /> Address---------------- --- -- - "!/-----------------------------------------------------------------------------------------•-•---------------------------------------------- <br /> Contractor's Name tls- n,3-.J •----------------------------- -------------------------------------------- Phone-- ._..._.. <br /> Installation wilt serve: Residence// Apartment House ❑ Commercial E] Trailer Court El Motel n Other <br /> Number of living units: _1.... umber of bedrooms 2. Number of baths ._.I.__ Lot size ----LO_$_�x_/�� f ` <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ........ ft. t `` <br /> Character of soil to a depth of 3 feet: Sand M Gravel ❑ Sandy Loam Clay Loam ❑ Clay El Adobe�ardpan E] V11► <br /> Previous Application Made: Yes ❑ No New Construction: Yes No [] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS- <br /> (No <br /> PECIFICATIO_N3S.: <br /> ( oPtic tank cesspoolP permitted public <br /> ._.s_e_-wer is available within 200 feet. <br /> Septi ak: tancefromneaesail_ = <br /> Distan��° fro faun ' ion-...�: ---------Mater'a <br /> No. of compartments------------- ------Size ..X.�___ Liquid do t ...... Capacity_--- 4� T • <br /> Disposal Field: Distance from nearest well__._."` _-Distance from foundation 1611. Distance to nearest lot lin _ <br /> j T <br /> Number of lines. .._..__- ... __. __Length of each line-.___...�__/3!.Q_r Width of trench_____________ __ _ f <br /> _ __ <br /> Type of filter material.... ._; ,-- p r <br /> " ��De th of filter material____..../ r________.Total length--------- �r <br /> ----------------•---- <br /> Seepage Pit: Distance to nearest wet!.....................Distance from foundation------.-------------Distance to nearest lot line._...-.-___--_--- <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-..------ -__...----Depth.........------.----__ <br /> Cesspool: Distares from nearest well-----------------Distance from foundation-----------------_ Lining material--. --------------------------------. <br /> ❑, __� Size:.Diameter - �» �- Depth--- �. a.. -- .,...._; ..�Ir�.quid_ Capacitac <br /> Privy: Distance from rearest well-------------------------------------.__......_.Distance from nearest building- __.___---_-___.-..-_--. <br /> ........... <br /> ❑ Disrance to nearest lot line-- --------------------------------------------------------_--------_--- <br /> Remodeling and/or repairing (describe):------------------------------------------------------------•--------- •-----.....--------------- <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, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)...:. LeL� /Ir-•. - ----------- -----••------•-••---- - --------------------(Owner and/or Contractor) <br /> By---------------------------------------------------------------------- ------ ------------------- ---------------------- (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 /> REVIEWED BY---------------- ---------------- DATE.. - <br /> --------•--------•-•--------------------------•-•-----------•--------------- -- <br /> BUILDING PERMIT ISSUED---------- --------------------•----•-•-------------------------------------------------------------- DATE--------------- <br /> Alterations and/or recommend ations:------------------------------------------------------------------------- •- ------ <br /> --•-------•------••------------•---------- <br /> .----•-•----•--------------- --•----••------•-----•-•............... ---••--•------•• --•-------•--------------------------------•----------------...._------------••---•----------- <br /> .....-•-- -•................................_...-----•.-------.. --. ------......_------- -.......-.-.._---.------------------•---•• ----•----------------------------­ <br /> -------- <br /> -----------------------------------------------..............•------•-•-----...---- ....-•----.........---------------------------.-.-.---.-----••----- ------------------•--•---•-•-••----•- ---------------- <br /> .- ...............................------------------ ---------------­------- -------------------••---. -------------------------------------•--------------- <br /> i <br /> FINAL INSPECTION BY:_- �16 Date D_�_ <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-9-21M 8-51 Revised W-2100 <br />