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10 U1. <br /> r <br /> APPLICATION' FOR.SANITATION PERMIT Permit " <br /> No. <br /> i f Q <br /> (Complete in Duplicate) Date Issued "" `a-"'5`3 <br /> Application is_herebytmade to the'San�Joaquin Local. Health,.District for a.permit to-construct'�nd install-thework herein described. <br /> This application is made in Eompliance with County mance No. 549. <br /> 'JOB ADDRESS D LOCATION--- ------ - f •--- ---- --= - <br /> -- ---------------- <br /> Owner`s Nam "_-- ' Phone- <br /> ---------- $�` <br /> - ---------------------------------- -- <br /> Address--------- ------ - - ------- - ---�+- <br /> --------------------------------------------------------------------- -------- <br /> �— Phone------------------------ <br /> Contrac#or's�'Name ------ - --------------------------------------------- <br /> Installation <br /> - r <br /> Installation will"serve: -Residence)) Apartment House ❑ Commercial ❑ Trailer Court ❑ Motfl ❑ Otthssef ❑ <br /> Number of living units: -_.L."l tuber of bedrooms .,Z"" Number of baths -"/--_ Lot size _ _ ___ �- -U---------------------- <br /> Water Supply: Public(system- --Community•system ❑^-Private=❑-Depth-' -------- ft.o atsr TableT <br /> _. <br /> Character of soil to•a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ONew Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: „ <br /> (No septic flank or cesspool permitted if publjc sewe iavaila6le within 200 feet. r <br /> k 1 �� <br /> Mater' IAj <br /> U - <br /> Septic nk: Distance from nearest wellQ-___-_""_Distances 'fro tfoution"".'""""___ f <br /> No:;of compartments--__------ _- -------- <br /> ------Siz _- Liquid 4epth -_ Capacifiy"""--- �_[- ---- <br /> s X <br /> `t { '0 � ��"""-Distance to nearest to#"I n "- ��` <br /> Dispos Field: Distance from nearest well __.�""__-".- <br /> stance from foundation_ may_. �r-----. <br /> f0 fo t Width of trench.----- +- _ <br /> Number of lines---------- ---- - Length of each line-- 1 33� eT----- t--------� � 1 <br /> Type.of filter materi ` epth of filter material---_.�_-O___L-___Total length" ��- �---� ! <br /> Seep it: Distance to nearest well-- ------- f om foundation-_--___•.-_--..._-_-Disttrce to nearest I lin_e_�__ -_.--__--_ <br /> Number of pits----------I---=------Lining material----,�`-'�'"�-�' ----Size: Diameter---?j�--------------.Qepth.-------� <br /> Cesspool: D+stance from n`earast welL_-_.__-""""__-_ Qistance from foundation--------------------Lining material----__-_---_---__----_---..--.-__--- <br /> ❑ Size: Diameter-- ----------------------------------Depth_----------------'----------- <br /> ----------------- <br /> ----•--� Liquid Capacity gals. <br /> ------------- <br /> --Distance from nearest buildingO <br /> Distance from nearest well----------------------------Distance to nearest lot line---------------------------------- = <br /> ---- <br /> Remodeling and/or repairing (describe):--------- ----------------------- ------•----------------------------- ------- ---------- ------------------------------------• ' <br /> _.« _ <br /> ---------------------------------------------•-------- <br /> ------•--------------------------------------`-------------•-------------- ----- <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 /> Si ned -----------------------------------------------------------------(Owner and/or Con <br /> (Signed) <br /> 9 ) G--- / d�o tractor <br /> .' ^""-----------------g-- Title <br /> s -------------------------------------- ------ - __ (Title) --- -- <br /> Y <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> DATC v-l' - -- <br /> APPLICATION ACCEPTED BY----' -------------------------------------- --------_­---------------------- J--...- <br /> REVIEWED BY DATE <br /> -eK <br /> BUILDING PERMIT ISSUED_. = --------------------- <br /> ---------------------- ---- <br /> ATE -•--------•------------------- <br /> - �y� <br /> AI rations and/or recommendations:------ - `r' ` tIT/e- ------- --------------••--------- .,--------- <br /> ---- -- <br /> VV <br /> + " <br /> ". .,�.---- -- -- <br /> ---------`. a -------------------------------------•---- <br /> ---------------------------------------------------- <br /> ----------------------------- <br /> f ------------------------------------------------------..----------- ---- <br /> �. r` -------------------------------- <br /> FINAL <br /> ------ <br /> •-.-- Date-... - `-' <br /> FINAL INSPECTION BY:-------- -------------------------- ------•--- _ <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 I0-52 Revised W-2100 f <br />