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APPLICATION FOR SANITATION PERMIT Permit Wo. _4---------------- <br /> (Complete in Duplicate) <br /> Date Issued <br /> plical-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.69CATIOP�------ - - ------- -------------------------------------------------------------------------- <br /> Owner7's Name -------- - ------- - -------------------------------------------- <br /> Address- - ------------- ----­--------- --- ---------------- --------------------------------------------------------------------------­­­­----------------------------------- <br /> Contractor's Name----------- ------ ------------ ------------ ------------------------------------------------- <br /> Instailationwill serve: �Residence Apartmen ouse E] Commercial F] 'Trailer Court -[] Motel F] Other E] <br /> Number of living units:A- Number of bedrooms_Z'l-Number of baths __/--- Lot size -a----------------------- <br /> Water Supply: Public 'syste MX Community system E] Private L] Depth-to Water Table44:0_14t.. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam E] Clay Loam'E] Clay E] Ado Hardpan Hardpan <br /> k <br /> Previous Application Made: 'Yes L] No New Construction. Yes ' No E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> .(No septic fank.or cesspool permitted if public sewer is available within 200 feet.) <br /> eptic Tanh Distance from nearest well._______.______.Distance from foundation------------ -------Materiai------------------------------------------------- <br /> No' of comparfmenfs--------------- ----------Size--------------------------------Liquid depth---------------- --------Capacity--------------------•-- <br /> 1 I . <br /> Dispos I lel Distance from nearest well------------------Disfance from fouhdation--------------------Distance to nearest lot line----------------- <br /> Njmber of lines-------i--------- ----- ------------Length of each line-------------------------._._.Width of trench--------------------------_--_----- <br /> Type of filter material-_________._____.______-------Depth of filter material_________ _____________Total length__--____-______________-_____----------- <br /> 00 <br /> Seepa e it: ,Distance.to nearest well-_,,-*-- <br /> e,frnoun, <br /> '/ <br /> n/o---- <br /> Ditance fo nearest lQ1Piin- <br /> fNumber of pits__:- ----- ---Lin;ng materia WeeS-2e: Diamef _ .DePfh__ A <br /> Cesspool: Distance from nearest well-----------------Distance from foundation____________.______ Lining material___-_-__._______________-------__--__ <br /> Size: <br /> aterial------------------------------------- <br /> Size: Diameter--------------------------------------De th-----------------------------------------------A---Li uid Capacity----------------------------gals. <br /> I <br /> Privy- Distance from nearest well_._____"____ -------------------- -Distance from nearest building. I_________ <br /> I] • Distance-fo' nearest lot line------------------ ----------------------- 11 _. ­ I <br /> -----------e_- <br /> ------------- - ------------------_ _-_---------------- <br /> Rernodelin%and/or re a ;be). ............2__: -- ----=------ ---------- <br /> --------------- --- --------------- ------------- ----------------------------------------------- -------------------------------------••---------•----------------------------------- ------- <br /> ---------- <br /> ---- --- -------- ------------------------------------------ -------------------------------------------------------------------------------­--------------------------------- <br /> -------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I-----------------4--------------- <br /> I hereby certify that I have prepared this application and that the work-will be done in accordance with San Joaquin County <br /> or iriances, State laws, an rues and re tions of the San Joaquin Local Health District. <br /> (Signed)--------- ---- - -------------------------------------------------------------------------------------- _.AOwner arrdi.gr Contractor) <br /> By <br /> -------------------------------- ____;-------------------------------------------------------------------------------(Title <br /> �------------ <br /> (Plot plan. showing size of lo location of system in relation to wells, buildings, etc., can be p9e6d on revers side <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ---------­-------------- DATE_Q,;�(�"'------------- -------------------------------------- <br /> REVIEWED BY--------------i------------------- -------------------------------------------------------------------- DATE -- ---------------------------------------------- <br /> Alterations and/or recomme ndations:__ ----------- --- --- - <br /> BUILDING PERMIT ISSUED------------7Z- ---------------------------------------------------------------------------------- DATE------ <br /> ---------- ---------- <br /> ------------I--------- <br /> ------------------------------------------------------------- c=-- <br /> ----------- - --j - <br /> -------------------------------------- -- -- - --- ---------------------- <br /> -------------:-- --------- -- - <br /> ------------------------------------ <br /> FINAL --­ <br /> ------------------------------------- <br /> - <br /> - <br /> - <br /> INSPECTION BY: --------------------- Date--------------------—------------------------------------------ ------------ <br /> 'JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Arnerican 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-2100 <br />