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APPLICATION FOR SANITATION PERMIT Permit No. 4// <br /> ----------7§42'. <br /> (Complete in Duplicate) Date <br /> -0 Issued <br /> Application is hereby made to the San 2a '0:� Local Health District for a permit to construct and install the work he ein described. <br /> This application is made in compliance with unf rdinance- o. 549. k he describe <br /> JOB ADDRESS IAP"DLOCA1_ <br /> -- -------------------- ----------------- --------- <br /> f Owner's Name <br /> ------- --- --------- -- Phone_ - <br /> ---------- --------------- - - ----- ------- <br /> Address---=----------------- ------- - ----- --------------- <br /> Contractor's Name____ ------ ------ 7� <br /> ----- --- ---- <br /> ----------------------------------------------------------------------------------------- Phone-------- <br /> ------------- <br /> Installation will serve: Residence Apartment House Ej Commercial Trailer CourtF [] lvlotpl Ll Other E] <br /> Number of living units: umber of bedrooms --°____ Number of baths Lot size __49S----- <br /> - --------------------- <br /> Water Supply: Public system Community system El Private E] Depth to Wafer Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam [] Clay Loam E] <br /> Previous Application Made: Yes [-] No ONew Construction: Yes ?,No o Clay El Adobe 0"/Hardpan Ej NSill, <br /> -TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool,permitted if public s 7 wer is available within 200 feet.) <br /> Septic/rank: Distance from nearest we1__!2----Distance frw fou clation----- __-____.Material-___._ -0.27 <br /> _Z - -- ----------- <br /> No. of compartments------------- ---- ------------0 qui e ------------------ <br /> VSize -,�_ _- �c----Li id d h --- ap city--tj <br /> Dis Field: Distance from nearest well-050 Distance from foundation____-- ---------Distance to nearest l2t I ie • <br /> P/ - --- I -------------- <br /> Number of lines__________9 . / of each line------------- Width of trench........ F <br /> ------------------ <br /> Typo of filter maferi4 -4- Depth of filter material <br /> _/ -----Total length----------llq�o_--------------------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation <br /> -----------------Distance to nearest lot line________________- <br />} -- <br /> Vd e <br /> Number of pits___`-----------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation_________-_______-Lining Lining mafe: rial----------------------1­1 Size: Diameter-------------- --- -------------------Depth----------------------------------------------------Liquid Capacity----------------- ---------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest buiJding----------------------------------------- <br /> 0 Distance to nearest lot line <br /> Remodeling and/or repairing (describe):___________________________________ _ I----------------------------------------------------------------------------------- <br /> ---------­------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------I --- ----- <br /> -- --- -- -------- --- - ---- <br /> I hereby certify that I have prepared this application and that the--work--will__6_e__done__in__accord_a_n`ce_­wifh_,Sa n__J_6��_a`quin_C_o_u_n+y` <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> {Signed)____-__1--- --------- ----5-A------51�- 4,N4& <br /> --------------(Owner and/or Contractor) <br /> --------------------------------------------------------------------------------------(Title)-- <br /> - -- - -- ----------------------------------------- <br /> (Plot plan, showing size of lot.. location of system in relation to wells, buildings, etc., can be place / ' <br /> on reverse side}. <br /> FOR DEPARTMENT UISEQNLY <br /> APPLICATION ACCEPTED BY--<Z--;,.... --------------------------------------------------------------- D AT E_ <br /> REVIEWEDBY-------------------------------- . --------------------------------------------------------------------- DATE------- ----- <br /> BUILDING PERMIT ISSUED_-__________________ <br /> ------------------------------------------------------------------ DATE-_-------- ---------------------I—------- <br /> Alterations and/or recommendations:________________________._______ ------------------------------------------- ----V-*%--------------------------------------- <br /> ----------- <br /> ---------- ------------ -------------------------- ----- <br /> -__,Q�------- —----------(�___--_----------- -------------------------------- <br /> ------------- -------- •----------------` ------------ -------- <br /> ------------------- ---i&----------------------------------------------- --------- <br /> ---------- --------- -- --------- ------- <br /> ----------------- -------- --- - ------ ---:�� -�w0 <br /> ---------------------------------------- -------------------;*�_�_------ iY —--------- <br /> FINAL 0IN'SiCTIO BY:----_----:_'--- ---------- --- -- ------------------ Date-------- <br /> -------------------------------------- <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 8-51 Revised W-2100 <br />