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kvll� 7 <br /> APPLICATION FOR SANITATION PERMIT Permit No.�� <br /> (Complete in Duplicate) <br /> Date Issued 7_ <br /> Applica-lion is hereby made to the San Joaquin Local Health District for a permit to construct and install the rein clet/cri3ed. <br /> This application is made in compliance v�ifh (;ounfj, Ordinance-No. 543—, 16"3- <br /> 6-1 <br /> JOB ADDRESS AND LOCATION--------(Z p 4 K <br /> 12so, D vl 40 <br /> --------------------------------------- 9_--------------------------------------------------- ------ <br /> Owner's Name-----------------------------------------F__ "-----07------M-FITZ �Ii------ - ------- ----------- <br /> 4'0 AL5 <br /> Address----------------- `` -`- !{ ( <br /> Contractor`s <br /> ddress------------------ <br /> Contractor's Name. --------------I-D XZ <br /> V7 <br /> -------------------------------------------- Phone.�---­-------------M_ <br /> Installation will serve: Residence ❑ Apartment House E] Commercial [-] Trailer Court [�j Motel L] Other [j <br /> Number of living units: ...-.--. Number of bedrooms -------- Number of baths -------- Lot size'.-------- ----------------- <br /> ------ <br /> Water Supply: Public system % Community system El Private F1 Depth to Wafter Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand 0 Gravel,F] Sandy Loom E] Clay Loom F1 Clay E] Adobe Hardpan E] <br /> Previous Application Made: Yes L] No %_ New Consfrurction: Yes El No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> -Sepfic4ank- 5,6-T'Ailslynce from nearest well-----------------Distance from foundation--------------------Material--------------------------- <br /> ❑ 4ZA14TW(No. of compartments--_.. ..- -----------------Size--------------------------------Liquid depth----- - ---------------Capacity----------------------- <br /> posal Field: Distance from nearest well- ?_�X- A_Distance from foundation--- <br /> pis -----..Distance to nearest lot line.--44-0- <br /> Number of lines-- --------Length of each line__---/�................Width of french,----* -- <br /> --- ------------------ <br /> F <br /> Type of filter maferial_k __ Depth of filter material----l. - - ------Total length__-- ----------------------------- 0 <br /> Seepage Pit: Distance' to nearest well__Z`tjeY€-L..-_Distance from foupdafion--ZA-------- Distance to nearest ]of <br /> Number of pifs.__�_k---------Lining material,_X/- Size: Diameter------- Depth--...: - -- ------------------- <br /> Cesspool: Distance from nearest w;I1-----------------Distance from foundation--------------------Lining material_---.._--------..._..-----.-..-_---._ <br /> ❑ <br /> aferia1------------------------------------- <br /> 0 Size: Diameter-------- ----- --------- ----- ----Depth------ ------ - ---- ------ -----------------Liquid Capacity--.-------------------------gals. <br /> Privy: Distance from nearest well------- -------------------------i-------------Distance from nearest building___---------_--------- ------- ---------- <br /> F1 - Distance-to-nearest lot line <br /> Remodeling and/or repairing (describe):------en---- __Z— ----------........... ------------ <br /> - ------7�,1 --------------I--------------------- <br /> ------------------------- <br /> ------------- ------- ---------------------------- --------- ------------ ------------ <br /> ------- ------ <br /> ---------- ---------- -----------------------­----------//------------------------------------ -------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------jV - ------------------------------------------------ <br /> ---------- <br /> I hereby certify that I have-prepared this application and that +he work will be done in accordance with San Joaquin County <br /> ordinances, State laws,-an -rules and regulations of the San Joaquin Local Health District. <br /> (Signed].... ---------------------/-------------------------------(Owner a-nd/9,F_-Contractor) <br /> --------------Z--- -------------- <br /> By:------------------------- ------------ If-41 ----- ---- <br /> :.6t---------------------- -------(Title)------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed n reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------- ------ ----------X-_(Z---------------------------------------- DATE--------- <br /> REVIEWEDBY------ ------------------------------------ ---------- -------------------------------------- DATE---- _ ------- <br /> BUILDING PERMIT ISSUED <br /> - DATE <br /> Alterationsand/or recommendations-----------------------------------------------------------------------------------------------•----------------------------------------­­----------------------------------- ---------------------------------------- ----------------------------------------------------------------------- <br /> -------------------------------------------------------- --------------------------- ------------------------------------- -------------------------------------------------------­ --------------------I------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - <br /> ------------------------- <br /> ----------------------------­------------- ------------------------------- <br /> l---------- <br /> - <br /> -.: <br /> ------------------------I----------------------------------------------------------------------------------------------------- <br /> IZie S <br /> FINAL INSPECTION BY:. -------------- -- ?�_ Date._..------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 30D 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 />