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Permit No. ll -0.4_ <br /> II <br /> WK, <br /> APPLICATION FOR SANITATION PERMIT ---- <br /> (Complete in Duplicate) Date <br /> Issued ____-__l h-- ---- <br /> Application is hereby made4c, the San Joaquin Local Health District fora permit f. -construct and install the work herein described. <br /> plicatiori is made in compliance "th County Or izance No. 549. <br /> - ---------- --------------- - ------- --------I--------I-------------------- <br /> Z;��DDRESS A CA N-- ---- ---- - ---- -- ------- -- ------- --------- ---- <br /> Name ---------- ----------------------- Phone------------------------------------ <br /> Owner's Name--- ---- -------------- ----- <br /> Address------------- ----- --- - - - -------------- - ---------------------- ------------ -- --- <br /> Contractor <br /> -------- <br /> Phone <br /> Contractor's Name-------------------------------------------------- ----------------- <br /> - 1h Com ercial ❑ Trailer Court 0 Motel 0. Other <br /> L Installation will serve': Residence'o Apartment House 0 <br /> . 0 % <br /> Number of.living units: -------- Number of bedrooms ______-------- Number of baths -------- Lot size -----------------------------­----------------------------- <br /> Water Supply: Public system E] Community system El Private P?-14fh to Water Table(e/747ft7 <br /> Character of soil to a'depfk of 3 feet: Sand [] Gravel E]­ Sandy Loam.E] Clay Loam o Clayo Aclobeo Hardpan z---_- <br /> previous Appli6afion Made: Yes [-], No gi-l"'New Construction: Yes E] No P,�-<A/VA: Yes E] No ❑ <br /> TYPE OF INSTALLATION -AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) <br /> Dist <br /> Septic TaDkz, Distance from nearest wellIA4 -- ------------------ ------------ <br /> ance fro foundat;on/42'4------ <br /> a C i <br /> No. of'compartments..........c=::�..........Sizeo ---)ev _!-Liquicl clep�h <br /> _�istance from founclafi�ni/R -1---Distance Disposal Field: Distance from nearest well,441�! to nearest lot line/69- <br /> 11 0,or <br /> 'Number of lines trench.___ -----------/ <br /> -------/4P---- Length of each tr <br /> Type of filter Depth of filter material___/-I--'-"-----Total length_______________________ e42----- <br /> to neare J7 <br /> Seepage Pi Distance to near) wellAW-1------------Distan Fm Pundafiion_c:�,,&O ist lot line--- <br /> Numbe.r of pits_ -----__----Lining material <br /> _2��. __.Size: Diameter--- Depth__,7,5__1---------- ------ <br /> Cesspool: Distance from nearest well_____________ Distance from foundation________________ ___Lining material________-_______________________ <br /> - 4 <br /> ❑ ,Size: <br /> aterial------------------------------------- <br /> Size: Diameter-------------------------------------Depth----------------------------------------- ------Liquid Capacity----------------------------gals. <br /> A <br /> Privy: Distance from nearest weh------ ------------------------------------------Distance from nearest building___-_---------_-_______________________-_. k1V <br /> ❑ Disfanc"e to nearest ]of line-----------------------I----------------------------------------------- ------------ ------------------------------ ------------------------ <br /> Remodeling and' -------------------------------------------------- <br /> /or repairing i ng (describe):----------------------------------------------------------------------------------------------------- <br /> l - <br /> ---------­------------I-----------------------:------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------ ---- <br /> --------------------------- ---------I-------------------------------------------------I---------------------:------------------------------------------------------------------------------------------------------- <br /> p <br /> -------- --------- --------------- ----- <br /> ------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------- ----- <br /> " --------- <br /> '�a e � <br /> I h eby ce fify hat f have prepared Ais application and fha+-+he work will be done in accordance with San Joaquin County <br /> p <br /> Iordinance Stat w , and rule and retionsof the San Joaquin Local Health District. <br /> ... . . ... <br /> ----------- <br /> ed) .. ..... .... . . - ---------- -------- ------ ---------------------- ��r and/or Contractor) <br /> sign --- -------------------- <br /> T <br /> By:-------------------------- • ------------------------- <br /> -- <br /> ------------------------------------(Title] --- .............. ... <br /> (Plot plan, showing size of lot, location of system in ela,_fi, n to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED 13Y_ --------------------- -- ---------------------------------------- DATE,�---- ------------------------------ <br /> REVIEWEDBY----_----------- 11-----------------------------------------------------------------I-------------------------------------- DATE------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED--------------------------------- ---------- -------------------------------------------------------- DATE------------------------------------------------------------ <br /> Alterationsand/or recommendations:----------------- -------- ------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------- <br /> Ii <br /> ------------------------- <br /> ------------------------------- ------------------------------------------------------I------------------ ---------------------- ------------------------------------------- <br /> --------------------e--------------------------------------------------- ------------------------------------------ <br /> -------------------------------------------------- ---------------- <br /> ------------------------------------- <br /> -------•----------------------------------- 11--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 0 ------------------------I-------------------------------------------------- <br /> --------------- ---------------------I- -------- ----------------------------_• ---•---------------------- <br /> t <br /> FINAL INSPECTION I3y:_,F/_- - ---------------------- <br /> Date- -------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American 300 West Oak Street [32 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> F5-9-2M Revises 1.57 F,P.CO. <br />