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APPLICATION- FOR SANITATION PERMIT Permit No. <br /> (Complete in.Duplicate} '� <br /> --Date Issued <br /> Applica*ion is hereby made to the Sari oaquin Local Health District for a permit to Construct and insfall the work herein described. <br /> This application is made in compliance with County'Ordinan e No. <br /> 549 <br /> JOB <br /> JOB ADDRESS AND LOCATION•. - <br /> . =:C�� . - ------- -----. <br /> ------------------s- <br /> -------------•---------- <br /> Owner s Name <br /> �---------------- • ------ - ---- - <br /> ---• - t <br /> t <br /> _-• ------------- - <br /> Phone <br /> Address--------- ° -----'------•--- 'Contractor's Name--- <br /> ' ----------=-------•------ <br /> " ------ Phone._.".--•-•-------------- <br /> - .:.-------- <br /> Installation will serve: Residence Apartment House❑ Commercial Trailer Court <br /> Number of living units: "".i! umber of bedroom ' ❑ ' ❑ M til ❑ Other <br /> r s _____ Number of baths __ Lot s,ze ..,Q_ f _7 <br /> ------------------ <br /> 1 <br /> Water'Supply: Public system :'Corrimunit~s stem❑ Private - <br /> � �,. . Y Y ❑ Depth•to Water•TableJ__"_:-�'ffi: �" - �"' <br /> Character of soil to a depth of.3 feed Sand.D GravelOSandy Loam Clay;Loam Clay E] Adobe Hardpan ❑ <br /> n_ <br /> Previous Application Made: Yes.❑ No New Construction: Yes 7o ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS:. <br /> (No septic tank.or cesspool permitted if publig sewer is)available within 200 feet.), , <br /> _"-"___t-ro istan a from faun tion"": " <br /> Septic ank: Distance from nearest well" '[}"'� Mater'a�l <br /> --------------------- -------------- <br /> No. of compartments8. _ _�__ �_._=._Siz q P. <br /> --�--� �-- - =Capacity <br /> 0.- t JT7"u-� <br /> 1 k I i ------------ <br /> Liquid e th_" <br /> .Disg from foundat on . " "_ stance to nearest lot,lina, <br /> Dispro�sal Field: Number ofolinesearest w II -.,r� ��en ails �f each line---(l�.Q------ ".•�_- idth of trench-------- -----�•��------------ <br /> Ll Type of filter maters " "" f - - T <br /> ---------------- <br /> Seepage Pit: Disftr <br /> ance.to nearest'welf_ Yy__ W"s__Distancef frotmrfoundation_._� _Distancertotal gohnearest <br /> ❑ Number of pits------ ----- --- --Lining .material-i ----- ----Size:'Diameter----•-- Depth------------ W <br /> Cesspool: Distance f,,- <br /> om.nearest well----------------Distance from foundation_."___--".-I___-Lining material_.--------_--_.__--._ <br /> ❑ Size: Diameter-----------------------= - Depth- '= - ` . . " . I :---------- <br /> Liquid Capacity-------- ---------gals. <br /> - t -w- <br /> Privy: Distance from nearest well-.------ { € <br /> __------- ------- Distance from 'nearesr.buil'din <br /> ❑ -to'nearest lot line_::"'-. '.r. �..,.__ 9------------------ <br /> Distance ------------- ----- <br /> ..,.� - +..-..�. 4 „ <br /> .. ......�------------------ -r , <br /> Remodeling and/or repairing (describe':__--"__"___--_._-------------- <br /> -------t - r �y <br /> •------------ ' 1 <br /> I - <br /> ---- -- { <br /> -- <br /> . - r <br /> ----------------------- <br /> --------------------­-- <br /> __""_"__"_." Y <br /> ._-"__""__.__"_""""_.."..""_"_.""."__"_.---------------------------------------------------------""_ i -,- <br /> ---------- <br /> ----------------------------------------------- <br /> y - !' .P pP =' ------------- - -------------- <br /> I ' <br /> herebycertify that I have preparted this a licatron and that the work will be done in accordance with San Joaquin County 't <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health Distriet� <br /> (Signed). _ d_ . I <br /> = --- --------------- ----- <br /> -- <br /> s - -- ¢--------------------------------------------------------------, w and/or Contractor) <br /> r BY: r <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings,-,etc:,'can be .placed on reverse side]. <br /> FOR DEPARTMENT USE ONLY i 4 <br /> APPLICATION ACCEPTED B _--_ --. 1 a "" _ 1 <br /> = -- ----------- --------------- DATE.,, - ------------- <br /> REVIEWED BY - - t DATE---rte <br /> Y _---. . -__� -"___-"_-------.-". --------------------------------------- <br /> _ __ <br /> BUILDING PERMIT ISSUED----- ------- ---------- <br /> ----------------------------- � - .1} <br /> --=-=-------------------------------------------------.." DATE.---- --�---------•---- ---------------=--••---- ' <br /> Alterations and/or recommendations:-------.----� i_" `� <br /> t •r ( h 1 --••----- <br /> ----------------•••--- .. <br /> ----------6y'r_"___ } 4 �Ykl.'Fa2.-___.f�t1l j�C ._.-..Y LL�i7�s-- ------------ ------- "• _ " " yK <br /> f1 � . "P.��hF37��r_,-------- '�------b4��'r:�?-, � <br /> i +Id- ��`���. s• - f "? htw--------t/4 ....... <br /> FINAL lNSPECTION-BY:----------------------- <br /> Date- <br /> ----- ---'!�l(f4= ll,---------- �,. . <br /> ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Nook "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M ; ' Revised W-2100 h <br />