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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in.Duplicate) Date issued Zle <br /> T- <br /> 1 7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the <br /> 1� qherein described. <br /> This application is made in compliance'with County Ordinance No. 54.9. <br /> JOB ADDRESS AND I- <br /> --- ----------------- ---------------------- <br /> Owner"s Name------- - U_474__ -----4------ <br /> hone.4- <br /> Address...­­­­..........­.............. <br /> --------------------------------------------------------------------------------------------------------------------------- ----------------------- <br /> Contractor's Name_---------- --------- --------- --------------------------------------------------------- Phon��.60; /eZ <br /> - ---------- <br /> Installation will serve: Residence Er--Apartment House E] Commercial E] Trailer Court ❑ M fel Ll Other 2-6-I'L <br /> Nu Number of baths <br /> ..Number of livingunits: A---- mber of bedrooms --4.- Num Lot size ------------------- ------------------ <br /> 41 .,iw, -- � - - '7-/-'-" - <br /> Wafer Supply: Public system El Community 'System'E] "'Priva-te-E]--�''Depth-tO..�Vafer Tab. 10-p ft. <br /> Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam E] Clay Loam ❑ Clay F] Adobe- Hardpan E] <br /> Previous Application Made:: Yes E] No Ej New Construction: Yes E] No Ej <br /> TYPE OF INSTALLATIOWAND"SPECIFICATIONS: <br /> (No;sep'+ic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Ta t Distance from nearest well-4__(7-"'__...__Distance from f9uncation-10- --------- -Majerial'-Z. <br /> mpWLiquid V <br /> pa <br /> DisposaIjield: Distance from nearest well-957jq------DTance from , <br /> found - -J-01------Distance to nearest lot line..__--------- <br /> Number of lines-_ Length of each linerfo.1<7 ._________.Width of french__qa_,/!��------------------ <br /> V,_ <br /> Type of filter rnater'ia -PA....Depth of filter rriat�rial----/ ----- Total length__��-------------------- <br /> I_-1_,y f <br /> Pit: Distan'Ce to -"-----D'stance fro- fo clation---- <br /> See f well _Distance to nearest lot <br /> Number of pit --- Lining material ...... -- ---- Size: Diameterj <br /> 7 al;- ---------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__--_.._____.____________'_________ <br /> ❑' Size: <br /> aierial_--------------------------------- <br /> Size: Diameter-___-,-----------------------------Depth------------------------------------------- -- Liquid Cappcify <br /> Privy- Distance from nearest well______________________________________- --__...._Distance from nearest building---------------------------------------- <br /> ❑ -Disfance-to nearest,,fof line-------- ------------------------------------------------------------------------------- -•----------------=------------------------------------- <br /> ------------------------------------------------------- <br /> . _ -- - -Refto eIing and/or Irlg'(describe -- -- - - -- -[ W1� , __Vj- - --- - e- ----------- <br /> —---------- <br /> -----------------------------------------------------------------------------------------------------------------......... ------------------------ --------------------------------------------------------------- <br /> ------------ -----------------------------------------­­-------------------------11------------------------------------------------------------------------------------------------------------------------------------------- <br /> I he efl'Wa_ve pre-pared fhi� application and that the work will be done in accordance with San Joaquin County <br /> hereby <br /> C 'bns of the San Joaquin Local Health District. <br /> ordinances, St- la 's'and rules a d r egu 1,at <br /> (Signed)------------- - --- ------- - -- - -------- --------------------------;.--:i------- ---- -------1Qw"er_=qwdftr Contractor) <br /> -------------------------------------- <br /> By:------------------------------------------------------------------- - -- -- -------- Title <br /> --4-t -------------- <br /> ion uildings, efc., can e p on reverse side). <br /> (Plot plan. showing size of lot, location of system relation �o.wells, b i�2II <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYa ---- - ------- DATE-M-----••------------------------------•-------------- <br /> --- -- --------------------------------------------------------------- <br /> REVIEWEDBY--------------------------------- ----------------------------------------------------------------------------- DATE----°® <br /> V^_-------------------------*------------------------ <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------------- ------­---------- --------------- DATE---------"XII----------------------------------------------- <br /> Alterations and/or recommendations:--.----------------------------------------- --------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------- ---------------------------------------------------- -----------------------------------------I-------------------------------------------------------------------------------------------------------­­ <br /> ....................................................I---------------------------------------------------------------------------------:----------------------- ---------------------------------------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------X;--------------------------------------------------------------------- ----- <br /> FINAL INSPECTION-.BY:._-.... --------------------------------------------- Date------- --------- —------ ------�qy------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American 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 />