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5 APPLICATION FOR SANITATION PERMIT Permit No. .... . <br /> �'r 1 (Complete in Duplicate) <br /> "'plica--ion <br /> LLL Date Issued __ <br /> • 1 <br /> AA plica--ion 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 /> -- <br /> ------ ------------------------------ ----------------------------------------------------- <br /> Owner's Name------- -�--- ----- -- - ---------•---------------------------------------- ------ ---------------- Phone----- <br /> Address-.................... R----- -------- --'-------'- - `---------------------------------------------------------.----------------------------•---q-------------/------------------ <br /> Contractor's Name--- -=------ ---•------ -------•---- --- ------s9-11.-t— ---------------------- ----------------------------------•-------- Phone--Z-/--IQ d ----- <br /> Installation will serve: Residence ❑---Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel ❑yy Other ❑ <br /> Number of living units: ---/- Number of bedrooms _=2_ Number of baths ---/--- Lot size .___I- _�J__f1.. -p_�-------------------- <br /> Water <br /> ___________Water Supply: Public system E2"' Community system ❑ Private [B""bepth to Water Table _-,4/l1ft: <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes 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 /> ❑ No. of compartments -------- ---------------Size-------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line____________..__. <br /> ❑ Number of lines-----------------------------------Length of each line------------------------�`_w Width of french------------------- O <br /> 5 <br /> Type of filter material----:------------ ----Depth of filter material-----------------------Total length-----------------------------------------� <br /> i <br /> Seepag if: Distance #o nearest well------- ____--------Distance from oun ----- to nearest lot line__ <br /> Number of pits--------�.-----------Lining material__L�___C __---------Size: Diameter_____�_�----------Depth__....A __________________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation___________________ Lining material_______.-________-.._____-__________- <br /> Size: Diameter_________________ __________________De th_.-___________-.______ _ ___ ----- ------Liquid Capacity gals. <br /> Privy: Distance from nearest well____'__________________-__..___.-._._________Distance from nearest building-----.------.----_________________._____- <br /> [] r Distance to nearest lot line--------- ------------------------------------------------------------------------------------------------------------------------------------ <br /> Remodeling and/or repairing (describe)-------------------------------------------------.------ ----------------------•------------•------- -----•------------------------------------------ <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)-------------- -- ---- ---- --- '------ -------------------------------------------- -----------•-------------{�6r.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 /> BUILDING PERMIT ISSUED--------------- - <br /> Alterations and/or recommendations:--------------------------------------------------------------------------••-----------------------------------•---------------------------------------- DATE---------------------------------------------- <br /> ------------•------•----------------•----------•--•---------------------------- <br /> ---•---------------------------•----------------------------­------- -------------------------------------------------------------------------------------------•------------------------ •---•-------------•------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------•-------- ------------------------------------ -------------- --------------------------------------------------------------------------------------...------ <br /> ---------------------------------- <br /> --------•---------------------------------------- -------------------------------------- ------------------------------*­--------------------------------------- •------- <br /> FINAL INSPECTION BY:........ ff _-. 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 W-2140 <br />