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Permit No. ......................... <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Date Issued --- ---------- <br /> work;herein described. <br /> Appliceicin is hereby made to the San Joaquin Local Health District for a permit to construct and install the <br /> ice with County rdinancp No SA9. <br /> This application is made in compliance �yp <br /> IDOCATION ---------------------- - --------*---------------- <br /> JOB ADDRESS AN ------------- —------------------ ---------------- <br /> C TION....... ...L---- <br /> 7D <br /> Phone. ----------- ----------I— <br /> Owner's Name- ------ ---- -- --- ................. ----- ---- ------- ------------- <br /> ---------------- <br /> 74 <br /> --------------------------------------------------------------------------- <br /> ---------• <br /> _---------- <br /> Address.---- ....................... ----------------- <br /> ----------•----- Phone- <br /> --]l----------------------------- <br /> Contractor's Name_____ �------------------ -&-- ----------j--------------------------------------------- I---------- ---------------- <br /> Instaliafion will serve: Residence [�J/Apar�tment House [I Commercial L] Trailer Court (11 Motel 0 ther D <br /> / h ------------------------ <br /> 11 aths Lot size --- <br /> Number of living units: ----V Number of bedrooms --107v. Number o <br /> Water Supply- Public sysfilm M Community system' 0 Pr Number <br /> to Water Table -------- ff. <br /> Character of soil to 6 depth of 3 feet: Sand E] Gravel [3 Sandy Loam Clay Loam El Clay 0 Aclobe; Hardpan <br /> ❑ <br /> Previous Application ade:. Yes E] No New Construction: Yes ;?No El <br /> �IN <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> or feet.) <br /> septic tank cesspool permitted if pu6Vc sever s available within 200 ee <br /> f ---------------- ------------ <br /> Se Distance from nearest we[15- 0,'7V Disf-a ro fou <br /> t <br /> Septic <br /> ---------Size_l_...CTZ.,----Liquid depth------- .......... ------CalAcify <br /> IFIX, <br /> No. of compartments------------- ------- ----- <br /> C j - / , J <br /> 0-;;rf o L <br /> ��istan`ce 'fr' - S 1 ' lotiine2�4� 4 <br /> D-ispo Field: Distance from nearest wel)z510 inclation-70 istance to nearest <br /> Le_0_.W'c1fh of trench_-] - --- ------------------- <br /> Number' of lines_- ------ ----Length of each line__._'j <br /> --- ---------- ------- <br /> Type of filter material'��_.!( ....Depth of,filter maferial- _________________Total length-------1-tic <br /> Seepage Pit: Distance to nearest well__--------------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> El Numbe'ri of pits--------------- ------Lining material----------------------Size: Diameter-----------------------Depth)--------------------------------- <br /> 11 . aterial-----ii. <br /> Cesspool: Distance from. nearest well-------- --------Distance from foundation--------------------Lining m --------------------------------- <br /> ❑ -ify !I- ---------------------gals. <br /> Size. Diameter----- ------------ ------- ----------Depth----------------------------------------------:-----Liquid Capacity <br /> Privy- Disfance from nearest well------------------------------------------------Distance from nearest building-----------I <br /> i-------------------------------- <br /> ❑ .......... -------------------- <br /> Distance to nearest lot line-------- ------------------------------------- ------------------------------------------------------------ <br /> Remodeling and/or repairing (describe):------------------------------------- ----------------­------------------------------. :-------------------•--•- -------------------------------- <br /> ---­------------------------ 1�. -----------------------------------------------------------------•-••--------------------------•--------------------------• 1------------------------------- <br /> ---------------tl�------------------------------------------------------------------------------------------------------------------------------------------------1�------------------------------- <br /> ----------------------------- I. - <br /> ------------- -------------------------------i-I----------------------------------------------------------------------------------- ---------------------------------------------------------I------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with S n Joaquin County <br /> Ity <br /> ordinances, State laws, and rus and regul tT*ON off the San Joaquin Local Health District. <br /> (Signed)----— W-D . ..... --- --------------------------------------------------------------------------(Owner,.and/or Contractor) <br /> By:--------------------------- --------------------- -- ------------------------------------------------------------------------------(Title)----I-------------------------- ------------------------------- <br /> (Plot plan, showing size of)ot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> --------------------------------- <br /> -------------- .... DATE------- <br /> REVIEWED <br /> ACCEPTED BY-----___���------ -------- ------------------------- <br /> REVIEWEDBY--------------------!1(---------------- ------------ ------- ------------------ --------------------------- -------------------- DATE--------------------•------11::-------------------------------- <br /> DATE--------------------------IM ------------------------------ <br /> BUILDING PERMIT ISSUED <br /> Alterations and/or recommendations:-- ------------­_­------------------- ------- ---------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------- ---------------------------------------- ----------------------------------------------------------------------- .................................. <br /> -----------------------------------ilm------------------------------------------------------------------------------------- ------------------------------------------------ --------------------------------------- <br /> - ------------------ -------- ------------ ----------- ------------------- -----------------------------------------A--------------------------------- <br /> ----------------I------------------I ------- <br /> ----------- --------- ......... -----------------------------------------11-------------------------- ----- <br /> ------------------ -------------------------- --------------------------------- ------- ---- ---------------- <br /> �1 16i� /6 ' ZL <br /> - <br /> FINALINSPECTION BY:-------- - --------------------- ------------------------------ Date-...-- ----------- - ---------- -------- -------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 814 No� h "C" Street <br /> 130 South American Sfr.[t 300 West Oak Street 132 Sycernore Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES 3-2M 145446 AT ..D ,Z-S4 <br />