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,t <br /> APPLICATION FOR SANITATION PERMIT Permit No- ---------- <br /> (Complete in Du licate) Date Issued ---- <br /> Application is hereby made to th-e Sa oaquin ocal Health District for a permit to constr;4ct and install the work herein descQ'bed <br /> This application is made in compli P ce with County Ordinance No, 549. <br /> JOB ADDRESS AND LOCATIO L.X_ <br /> --------------------- -- ---- ---"0 <br /> ------- --- ----------------I <br /> 41 <br /> Owner's Name----------------------------- <br /> ....... ------------ ------------- Phone_.-•--- <br /> Address.- <br /> ----, = ------------------------Address-------------------------------Z.�/7---- <br /> ------------------------- <br /> Contractor's Name------------------------------------ -------------------------------------- -------------------'------------------ Phone----------------------------------- <br /> Installation will serve: Residence [] Apartment House E] Commercial E] Trailer" Court [j- Motel E] Other E] <br /> - -to ---a/�O,( <br /> Number of living unit;: V--- Number of bedrooms�13__ umber of baths /___ Lot size e� Q_________________________ <br /> Water Supply: Public system X Communify'sys Private 0 Depth to Wafer Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [] Clay Loam E] Clay Ej Adobe E--'Ha rdpa n E] <br /> Previous Application'Made: Yes E] No �eW,Construction: Yes to E3 FHA/VA: Yes ❑ No� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or'cesspool permitted if public,sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest Distance r0founcLaf;on-/e- ---. <br /> ---rx- MateriaI---- - <br /> No. of compartments--_____ -- <br /> - - ---size-, 1 Liquid depth-- - --------Ca pacity____ _____ <br /> ?_ep: - <br /> - <br /> Disposal Field: Distance from nearest fion_/g042r_-^,Distance to nearest lot <br /> 7 Ce T.omfounda <br /> Number of lines_______- R o <br /> -------- .. ..... ... Vn g fline-_____`f<�_' --------Width of trench-- ------------ <br /> Type of filter mter-,,I__ !;X Depth of.filter material......If-----------Total length_____A.,.--e6-- '.---------4 <br /> w isfance,sfrp_m*' foundafion------ - -- ------DisTance to nearest lot, line---k's-1..... <br /> ost?�:�6 'IVR Distance to nearesf,� ell__ -------------:_- ho., <br /> R7 Number of pits-_1--------------Lining material-! Size: Diameter_ ! 1�_' Dept h----- <br /> ------------------ ------ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material__-_-_----__--_____-______-_________ <br /> ❑ <br /> naterial------------------------------------- <br /> El Size: Diameter-- ----------------------I-------------Depth-----------------------------------------------------Liquid Capa'cify---------------------- ----gals. <br /> Plprivy: Distance from nearest wel#-------------------------------------------------Distance from nearest building______________-__________---_-______----- <br /> [] <br /> uilding---------------------------------------- <br /> Distance to nearest lot line------------------------------------------- ----------------------- <br /> Remodelingand/or repairing {describe)-------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------:----------------------------------------- <br /> -------------------I-----------11----------------------------------- ----------------------- -----------------------------•---•-•-•--•-----•--- ----------I--------­------- ------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------�;----------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepir;d this application and tha-it the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and reg atiiof thi San Joaquin Local Health District. <br /> ------ ------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> (Signed)------W-4141-1v--- <br /> By:----------------------------------------- --------------------------------------------------------------------------------------- <br /> (Title]_ ------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 0 DEP <br /> NT USE^, LY <br /> - <br /> APPLICATION ACCEPTED BY-------- -- --- ------- ------Z- --------------------------------- ••--------------- . DATE_____j�,7 <br /> 5_7------------------------ <br /> REVIEWEDBY-------- - --------------11--------------------- ------------- ------------------ DATE--------------------------------------------- <br /> ----- ------------------------ ----------4. ------ -------------- <br /> BUILDINGPERMIT ISSUED------------�J ------------------------------------------------------------------------- DATE-------------------•----------------------------------- <br /> Alteratipris and or keco wfn..d.F.ori1s; ----------- -----------I------- --------------------------------------------------- <br /> V ---;e ...... <br /> --- --------------- ---------/ <br /> - ----------------------�Vh--------- - ---- ------------ <br /> ---------- --------------- ------------------- <br /> ---------- <br /> —----- ------------------------ <br /> ------- ------------------------------------ <br /> ---- -- - - - --------- <br /> -------------- <br /> --- -----­------------------ ----- -- -------- -- ----- ------- --- ---------- <br /> FINAL INSPECTION BY:__ -------- - <br /> ---- ----------------- Date-------------------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH•DISTRICT <br /> 130 South American St I reef 300 West Oak Sf reef 132 Sycamore Sfreef 014 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-4-2M Revised 1.57 F.P,C0. <br />