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VA <br /> \4y APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued --- <br /> �37tt <br /> Applical-ion is hereby made f&"the San Joaquin Local,HealW District for a permit to construct and install b#work here' cl cribed. <br /> This application is made in compliance with Count Ordinance No. '54 <br /> JOB ADDRESS AND LOCAWN....... _U#14�_ --------e <br /> ---------- <br /> Owner's Name_------------ ------- ----- ----------------------- ------------------------------------ <br /> Address......................... ­-------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------ <br /> Contractor's Name----------------jo-9" -----'--------------------------------------------------------------I ------------------------------- Phone----------------------------------- <br /> Installation will serve: Residence e-1rpP0a'*rtmenf House Commercial [] Trailer Court F] Motel F1 Other [I <br /> Number of living units: N ber of bedrooms ---- Number of baths I---- Lot size ---- _(07_IED.... <br /> ................. <br /> Water Supply: Public.system ;���unify system E] Private 0 Depth to Water Table f+. <br /> ,�Gravel F y El <br /> Character of soil to a depth of 3 feet:' Sand 1� _] Sandy Loam E] Clay Loam 0 Clay ❑ Adobe✓kr'9a­rdpan El <br /> Previous Application Made: Yes [-] No V-,--5ew Construction: Yes <br /> TYPE.OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank:or cesspool permitted if pu lic sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_06-0--'Lf-Distance frorpLfounda;wi___/_V___L....-.Mater', - ------ <br /> No'. of compartments____ --------Size----/01 0--^---&_Liquid depth____________ ___ Capacity., <br /> i7 <br /> nearest I <br /> Disposal Field: Distance from nearest well Distance from foundalio t__P!_,J------Distance to nearest lot I ----------- --- <br /> Wmber of lines----------- Length of each line------ Width Of french------ -------------------- <br /> Depth of <br /> Type of filter- materi6l--- filter material_._._ ---Total length_______._-fj---------------- <br /> L ,L-4 <br /> Seepage Pit Gn <br /> Dis 'cJfo nearest W _' <br /> `e��_ _-__­__ _______DisTanc`e ironr7foundation-L1_1------------Distance to nearest lot line__-------------- (!�} <br /> Number <br /> ine----------------- <br /> Number of pits----------------------Lining'material-----------------------Size: Diameter--- -----------------Depth---------------------------------- <br /> Cess'pool: Distance from nearest well-----------------Distance from foundation------1------------Lining material------------------------------------- <br /> F1 Size: Diameter---- ---------------------------------Depth----------------------------- ----------I-----`-----Liquid Capacity----------------------------gals, <br /> 11 <br /> Privy: building-_______-.__--_-_--_----._-_.----_---.-. <br /> - <br /> Distance from nearest well---------------_____,_---.___,--__.--.___------------- -------------------------------:----Distance from nearest building------------------------------------------ <br /> ---------- -------------......--------------------------------------------- -------------------- <br /> El Distance to nearest lot ---------------- 4 4­ <br /> Remodeling and/or repairing (describe):----------------------------------------------------------------------------- <br /> ---------- -------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------- ------------ ----------------------------------------­------------------------------------- <br /> ---------------------------------------------------------- -------------------------------------------I------------------------------6f <br /> -------------------------------------------Z; <br /> ..........7-11---------------------- <br /> --------I---------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------G <br /> I hereby certify that I have prepared this application and that the work will lee d;ne in accordance with San Joaquin Coun <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. -. I, <br /> (Signed)------- -------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:....................__------------------------------------------------------ -------------------- -----------------------------�_(Tifle)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed-on reverse side), <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- -------- -------------------------------------------------------- DATE---------- ---'� - -� ---- ----------------- � ' <br /> REVIEWED <br /> ATE------ <br /> REVIEWEDBY_--------------------- -- ---- -:-------- -------------------------------------------------------------------------------- DATE------------------------------------- <br /> BUILDING PERMIT ISSUED--------------------------------------- DATE...: <br /> Alter ns an recoendaflons:�. _`n,_' <br /> ------- --- - ---------------- ----- ------- - ---------------------------- <br /> ------------ --------- <br /> ---------­-------- ----------------------------------------------------------------------------------------------------------------------------------------------------- _ --------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------_--------_•-------------------------------------- - --------------------------------------------- ----------------------------- ----•----------------------------------_._..-------- <br /> FINALINSPECTION 'BY--------- -- ----------- ----------- Date-----------------------------I------------I------------- --- ------- <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, Califqrnia Tracy, California <br /> ES-4-2M ; . Revised W-2100 <br />