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a tit <br /> Z� APPLICATION FOR ANITATION PERMIT Permit No. <br /> [Complete in Duplicate) Date Issued <br /> Applica4ion is hereby made to the San Joaquin Local Health District for a permit to constr&I and install the work herein described. <br /> This application is made in compliance with County Ordin nce No. 549. <br /> ,_541,A)- 1-E 0 L,`—Y d2_ - - -_-—........4144.0 <br /> JOB ADDRESS AND LOCATel ��! ... ... <br /> - e............ ------- <br /> Owner's Name--------------- In <br /> Address---...91 ------------ .. . ............. ....C-1 <br /> # - ,12r -- <br /> Contractor's Name.-•- --- .... -- ---------------------------------------------•------------- Phone.................-------•--------- <br /> installation <br /> ................----------------- <br /> installation will serve: Trailer Court [I Motel [:1 Other F <br /> Residence Apartment House El Commercial F -1 <br /> ] <br /> �It <br /> Number of living Units: __ Number of bedrooms 2_0. Nu I mber of baths J--- Lot size ........... <br /> Wafer Supply: Public system El Community system E Private [X Depth to Water Table /0- ff. <br /> Character of soil to a depth of 3 feet- Sand [] Gravel [] Sandy Loam El Clay Loam [I Clay 0 Adobe;y Hardpan [] <br /> Previous Application Made: Yes E] No r7 New Construction: Yes 0 NoEl <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No sopfic,+ank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sept' Tan 0 k stance from nearest well-__-------------Distance from founclation,_-----------------Mdterlal.....................................__-------- 1j) <br /> X, <br /> ---Liquid depth--------_--_-_- Capacity---------------------- <br /> 0. 0. compartments_.........................Size--------------------------- <br /> Z lot <br /> Disposal f=ield: Distance from nearest,well__.__7 Distance from foundation 1aL.,...__Distance to nearest <br /> Number 0)' lines---------_I---------- Length of each lire-_-_-"1�_�_ ----------------Width of french........24A_ <br /> Type of filter mate Depth of filter mate rial....1--c <br /> y r -----Total length.L...../-ja_------- ............ <br /> `tel <br /> Seepage Pit: Distance to nearest well......................Distance from foundation...............---.Distance to nearest lot line____..-.-.-.___-_ <br /> ❑ <br /> ine----- ----------- <br /> 7 Number of pits......................Lining material......._....._...__:__.Size- Diameter----------------......_.Depth................................. <br /> Cesspool: Distance from nearest well.............._.-Distance from foundation-------------,!-.-.Linin§ material__..__...__....._...-_............... <br /> 01 Size: Diameter_-----------------------------------Depth------------------__ --------------_---_Liquid Cap -gals.2�;j ty-----_­;- ls.------------:7 . _.- - <br /> Privy: Distance from nearest well............... ............------------------Disfance from nearest b.uilcling__.-------------------------_---_----- <br /> Distanceto nearest lot line---_.........----------------------- --------------- -------------------------------- ....-----------•---- -------._-.,-.--.----- <br /> 7t <br /> Band ....... ------- .............. <br /> RernVoddell'. I r re ding (des rib ........ . ....... <br /> Z . " " 0 - - - <br /> ...... <br /> ------ ---- -------- <br /> ------ ---- <br /> ------------ e <br /> 22- le-------------- <br /> III be done in a rdance with San Joaquin County <br /> p <br /> hereby certify that I have prepared this plication That +he work will <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> ..[Owner and/or Contractor) <br /> (Signed)------------------------------------- ...............................---••-.....__.............................................. ------- <br /> B - -------------{Title).....---------------------------------------------------------- <br /> .. ........ -----_---------- <br /> 'Fon to wells, buildings, etc., can <br /> (Plot plan, showing size of lot, location of Mf&m in relation be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- -------------- DATE.............................••----.._...-•----. --------- <br /> REVIEWEDBY------------------- ---------- ------------------ ........ --------------------------- DATE.—_.—.......................................... ------- <br /> BUILDING PERMIT ISSUED...... DATE....... ........._.........-.--..-------•-----•-.-•- <br /> ..........------- <br /> Alterations and/or recomrnenda,'pnsl ...................... - --------- ....... <br /> 4 <br /> ----------------- ----- <br /> -------- . . ................ -----------­---- <br /> ------------ ..... �- -_ --- <br /> -----------------__. ------------- ........................ .................. <br /> sJr ..................................................................................................... ................................... <br /> ------------------------ ......... ..........................------- <br /> .. . .... . .1 -i _11y-------1p� <br /> -6 <br /> FINALVLPECTIUNBY:---------------------------------------------------------------- Date----------- -------------------_ ---------------- ---------------- <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 i - Revised W-2100 <br />