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y APPLICATION FOR SANITATION PERMIT Permit <br /> (Complete in Duplicate) Q <br /> Date issued _l_- <br /> Applicakion 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 /> JOBADDRESS AND LOCATION -------------- ----- 6'/�-------- �>.v.....t-----------------------------------------------------------------------------------------•-- <br /> Owner's Name lx�- 61"t �'. "= v U I � Phone------------------------------------ <br /> Address---------------------------------- ------------------- -•- --- <br /> ---------------------------------------------------------•----•--------------------------- .._-------------- <br /> Contractor's' Name------------------------------------- �5�►^tir _' r---------------------------------------------------------•--- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E]Number of living units: --------\Number of bedrooms --.- Number of baths -1----- Lot size ------------A_ _-Aclre___ ___________________ <br /> Water Supply: Public system ❑ Community system ❑ Frivatey Depth to Water Table __ 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 ❑ NOX New Construction: Yes IF, <br /> 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-----�a_ _Distance from foundation____ ._.-------Material-------- ------------ <br /> S-X f el"j----Liquid depth------- ---------Capacity---...klej <br /> No. of compartments------------- --�---Size.___._. _ <br /> Disposal Id: Distance from nearest welL._.�(f___Distance from foundation___ -__�_f Distance to nearest lot line..... _ <br /> Number of lines-----------.Z_____ Z1------Length of each line___ __-__,j(U-----Width of trench._________Z`'17- <br /> ------------ <br /> 11 <br /> TYPe of filter material--- ��:--__Y40epth of filter material-------l��-------Total length- ------- 1 ---r------------------- <br /> Seepage Pit: Distance.to nearest well----------------------Distance from foundation-----...............Distance to nearest lot line--__----_--______ <br /> ❑ Number of pits----------------------Lining material----------------------.Size: Diameter--------------.--------Depth-----.-_-----------_------------- <br /> Cesspool: k Distance from nearest well-----------------Distance from foundation--------------------Lining material_________________________________-__. <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____._____-._-_-____---_____._____-__. <br /> [l Distance to nearest lot line---------- ---------------------------------------•------------------------------------------------------------------------------------------- <br /> Remodelingand/or repairing (describe) - ----------------------------- -----------------------------------------------------------------------------------------------------•------------ <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 andregulatio s of the San Joaquin Local Health District. <br /> �-------------- -----------------------------------------------------------------------(Owner and/or(Signed) Contractor).._ - <br /> By:..7 ----------•--•-----------•------------------------------ --------------------------------------•---------(Title)--- -.------------------------------••--------------------------- <br /> (Plot <br /> ------------------- <br /> � <br /> (Plot <br /> 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 /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------ ----------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:-------------------- - ------------------------------------_------------------------------------------------•----------------------------------------------- <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 /> ���� <br /> Stockton, California ,/California ' Manteca, California� Tracy California <br /> Cal�iforn�ie+ <br /> ES-9-2M Revised W-2100 <br />