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1 APPLICATION FOR SANITATION PERMIT Perm'i�!No `'`_ <br /> [Complete in Duplicate] - <br /> } Date Issued <br /> f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herei ibed. <br /> This ap lication is made in compliance with County Ordinance No. 549. _��i <br /> JOgADDRESS AI CAT <br /> IO d <br /> - -------- ,� - --- ---------- <br /> "S' <br /> Owner's Name---- -- <br /> Address <br /> -� Phone <br /> - - -------- <br /> Address- - ------------- <br /> ------------- <br /> .. <br /> Contractor's Name -- --- •- --------------- Phone--_, <br /> �-2 <br /> _ j------------ <br /> #nstallation will serve: Residence Apartment se ❑ Commercial ❑ Trailer Court 0 Motel Other <br /> Number of living units: _- ___ Number of bedrooms Number of baths _/__. Lot size __ -------------------------------- <br /> Water Supply: Public system [❑ Community system ❑ PrivateX Depth to Water Table-:�?Q ft. <br /> Character of soil to a depth of 3 feet: Sand, Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ NoNew Construction: Ye� No ❑ <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 well--------------'_Distance from foundation--------------------Material_____.____-__________._ <br /> L No. of compartments Size----•---------------------------Liquid depth- -----------° --------- --------------Capacity----------------------- <br /> Disposal Fie! Distance from nearest weli___ Distance from foundation-- <br /> Number <br /> ---------.Distance to nearest lot line__-,�_ ___ <br /> Number of lines------ Length of each line_____ __._1l -- Width of trench- __ ____.___ <br /> ............ <br /> Type of filter material _ . '--------Depth of filter material___�.-__.._ -Total length---------_�9_���------------------- <br /> Seepage Pit: ,Distance to nearest wel► 104........Distance from f "ndation_—/_/____.Distance to nearest lot line___.`__._-___ <br /> - Number of pits-- material - _'`Size: Diameter---- Depth__ /3 <br /> -- - <br /> f �--- --------------- <br /> Cesspool: Distance from nearest welt___'___________Distance from foundation__________________ Lining material_________________________ <br /> Sizc: Diameter------------- ----- ----------------Liquid Capacity----------------- ----- <br /> ------ -----Deoth---------- - -------------------- ----gals. <br /> Privy: Distance from nearest well--_'"=_-_',`--'--'_____________'._____- --r_--Distance from nearest building ------------------------ -------- <br /> ❑ Distance to nearest lot line <br /> --------- <br /> . ----- �----- - <br /> Remodeling and/or re aig (describe): <br /> — - -- --- G�---te---r <br /> --'-"•'-�? <br /> y <br /> - - �i '-.� -_--� - - - <br /> ___ _ _________ . --------------------- <br /> ----------------- <br /> - <br /> ---------------------- ------------------- rZ <br /> _ <br /> ---------- -- <br /> I hereby 'certify tha I have prep red this application and�ha+ +he work will be done in accordance with San aquin Count <br /> ordinances, State la s, and rule eguI tions of t e San Joaquin Local Health District. <br /> (Signed)----- ------ �� -- --- ----- ----- . <br /> ,� _{ �- ,� __ Ownerand. <br /> Contractor) <br /> A By----- ---------------------=-- -------�- <br /> - n or <br /> (Plot'plan, showing size of Ib#, location of system in relation to wells, buildings, etc., can be Ia ed on revers side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----------------------------------------------------I- DATE--------------- <br /> �, --: ---- s--------- <br /> REVIEWEDBY = ----------------------------------------•--------------------. DATE <br /> --------------------------------------- <br /> UI DIN PERMIT ISSUED------------------------------------------------------------------------ -------------------------•--- DATE---- ---------------- <br /> ------------------------ <br /> Alterations and/or recommendations------------ --------------- -=_--=------------- ----------•-----------••----------•---------------- <br /> ------------------------------------------------- ------•• ------------------------ -------------------•------ ------------------- <br /> ----••-------------------------------------------------------- ------------------------- --•-------------------•------------------------- •-------------•.----- <br /> --------------------------------- <br /> ­----------- ---------- -------------- -------------------------------------------------• -- <br /> FINAL INSPECTION BY--------------------r ------------ -------••---- Date--- . ....... <br /> , <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 �c-52 Revised W-2100 +' <br /> 1 - 11� V <br />