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jP_4 <br /> Permit No. <br /> APPLICATION FOR SANITATION PERMIT <br /> �a_ (Complete in Duplicate) <br /> Date Issued -_a -- <br /> 4j '.Health District for a permit to construct and install the work herein described. <br /> ,r1rication is hereby to the San Joaquin Local <br /> This application is made in compliance with County 0granc, 9. 9 <br /> 'Ica ---------1�-------------------- ---------------------------------------------- <br /> JOB ADDRESS D LOCATI --- - - ------------- 111 <br /> - <br /> Owner's NaMe ------ ------------- ---- Phone--------—-------------------------- <br /> Address... <br /> ----------------------- <br /> ------------------------------------­­----------------------------------- <br /> Address..-------6__�--- ----- - -­ ------ --- ---- -----I----------- <br /> Contractor's Name-- ---- ---- ------------- - ----------------------------------------------------------------------------------------------------------- Phone--------------------------- ------ <br /> Installation <br /> hone----------------------------------- <br /> ❑ <br /> Installation will ser.ve: Residence Apartment House E] Commercial E] Trailer Court E] Motel their. <br /> Number of living units: J---- Number of bedrooms Number.5kbafhs I---- Lotsize5Z�V- --------------------------- <br /> Water Supply: Public system El -Co'nimunify. system El Private U3Arbepth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feef:� 'Sand [] Gravel El Sandy Loam [] Clay Loam ❑ Clay [] Adobe�arclpan E] <br /> Previous Application Made: Yes [I No [+ / New Construction: Yes [/No [I <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pubic sqw?r is available-within'200 feet;) <br /> Septic nk: nearest well sfan ce, frog jovac�ation_/_S��Aat I I--- ---4----- ---4 ----- <br /> Distance from n r <br /> X8 - -j _T1 - -----Capacity--- -- --- <br /> No, of compartments--.-- 'SqC9__K_y_Y4>-----.Liquid depth_- -_- e <br /> I r–,5 <br /> 101 �Disfance to nearest lit i <br /> Dispos Field: Distance from nearest we! __.._ iitance"from foundation <br /> f 'T <br /> ­,N-mber o�- Length. I each line--------- ----Width o trench_._._____ ----------------- <br /> Ey 0 aterial-. --------Total length--------- -------- ---------------------- <br /> f <br /> Type offiltermat 'Iter m <br /> e oi ,Depth <br /> 0 00 <br /> � <br /> from foundation-------------------rDistance to nearest lot line----------------- <br /> Distance to nearest i't <br /> Ir - <br /> Seepage Pit: -- - -------- D aincl, <br /> -------- =----------Lining material-----------------------Size: Diameter-----------------------Depth------------- ------------------- <br /> ❑ Number of- pifs-I-. C06 <br /> Distance from' well-----------------_---Distance from foundation---------- ---------Lining material-___--___--_-_--------------------- <br /> Cesspool: - : ------------------Liquid Capacity----------------------------gals. <br /> F1 Size: Diameter-------------- <br /> ;ameter-.------------------ -------------------Depth;:--------------------------------- <br /> 'A ' =t 'building------------'-----------------i <br /> Privy-. Distance from nearest well__----------- -------------------------------- ce fr8rn nearest ------------ <br /> F1Distance to nearest lot line--------------------------------------------------------------------- -------------------------------------------------- ------------------ <br /> 410 r leli.ng and/or repairing (cItscribe):-----_4 ------------ ----------- ---------------------------------------------------------------------------------------------------------- <br /> ... -- ------------------------------------------------ -------------------------------------------------------------------------------------- <br /> ----- --- ---- --- ----- ------ <br /> --- - <br /> ---------------------------------------------------------- <br /> --------------------------------------------------------------------- <br /> ----------------- ------------------ ----------------.......------------ <br /> . - <br /> 0 �­ , ---------------------------------------------------------------------------------------------------- -------------- <br /> -----------------------------------------------•------------------I---------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed}_ ----------------------- --------- --------------------­------- -------------------------------------------(Owner and/or Contractor) <br /> ------------ <br /> By:------------------------- - <br /> ---------------------------------------------------------- ---------------------------------------------(Title)---------- -------------------------------------------------- <br /> (Plot plan, showing size of lot. location of system in relation to wells, buildings, efc., can be placed on reverse side). <br /> T <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED B -- - - ------------------------------------------------------------ DAT --------------------- --------------------------- <br /> 'RE-V--I-E--W-----E-D-----B--Y--------------K------.------------------!-----1-------------------------- <br /> -----------------------------------------------------c-----P---------------------------- ---------------- - DATE -- ------------------------------------------------------- <br /> --- <br /> BUILDING PERMIT ISSUED------------ - -------------------------------------- ------ DATE---- <br /> --------------------------------------- <br /> Alterations and/or rpcorgnendations:------- - ------- -- ------------ --------------------- - <br /> 1 ---- <br /> I - ---------------- ---------------------- <br /> - <br /> - <br /> ----------------------- ----------------••-------- --------- -------------------------- ----------------------------------- <br /> ------------­----------------- ------ I ­------ ----- ------------------------------------------------------------------------ <br /> --------i-------------------------------------------------- ----------------------- ------------------- --------------------------------- <br /> -------------------------------------------------- ----------- --- <br /> -------------------- --------------- - ------------------------ ------------------------------- <br /> rr <br /> FINAL INSPECTION BY:. _,e----- t7_ ------ -------------- <br /> Date-. ------------- ------ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West CA Street 132 Sycamore Street 814. North "C" Street— <br /> Stockton, California Lodi, California Manteca, California Tracy..California <br /> ES-9-21v1 !0-52 Revised W-2100 <br />