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Q <br /> J APPLICATION FOR ,E ANITATION PERMIT Permit No. <br /> (Complete in Duplicate) �Z <br /> Date Issued -- ------•------ _ <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION-----= 302 5.-------E---------- LOA .=--------f ----- -- <br /> Owner's Name------------------"----------- Ll-do_ u {-u-t�ij� -? ---------- ------------------------ ----. Phone---------------------- - ---•---- <br /> - ;. - <br /> Address----------------------- = <br /> --------------------------- - -------------- -------------------------------- <br /> Contractor's Name-------•---•--- . r --- -- --- - Ph,ne----------------------------------- <br /> Installation will serve: 'Residence E] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __.___:_ Number of bedrooms -- Number of baths ________ Lot size -----------------------__________________.____________-.__ <br /> Water Supply: Public,systeni ❑ Community system ❑ Privdte ❑" Depth to Water.Table..___---- ft. . ' .. <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 ❑ New Construction: 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 well_____N.(7-----Distance from foundation____ -----------Material_______:_ _ �d ----,--------------- <br /> - <br /> ry <br /> No. of compartments = Size ? -------Liquid depth----------VA-`_ - Capacity------�5-q (tv <br /> Disposal Field: Distance from nearest well_____ _L2_...,Distancel`from foundation-__-__ _ / <br /> p �� I _________.Distance to nearest lot line..___ .... <br /> Number of lines---I-------- ----------------w"._'Length of each line__----7d---X ----Width of trench---------� yC_/�-----------• -- <br /> F Typeor'rf�ilter material_____-_(_��______._.___Depth of filter material___.-_� ___-___--_-Total length__'__________1,_Q__ ________________ <br /> page Pit: Di�tance ito nearest well--.__. ---------__._____Distance'from foundation___.__ ...___,Distance to nearest lot line--____ <br /> Number of pits- ------------ -:_____.__Lining material. ____0'.._Size: Diameter----4-6-------------Depth---------- <br /> .,. '___ <br /> ---------- <br /> Cesspool: Distance,from nearest well-----------------Distance from foundation--------------------Lining material----------------------------___----- <br /> ❑ Size:,Diameter------_;-` '� ~:----- ------- Depth---�!'-------------------------------------------------Liquid Capacity-----------------------------9aIS. <br /> a <br /> Privy:' Distance from nearest well.__.------- ------------------Distance from nearest building----------------------_________;---------- <br /> ❑ m, M A. <br /> Distance to nearest lot'line- -------- - -- --- =- - . <br /> -----------------------------•---------------------- ------------------- ------------------------ <br /> I t :. <br /> Remodeling and/or repairing (describe):--------------------- --------- - "- --------- ;f-------------------:-•-------•-----•-•--••------••--•--`--------- <br /> M T T� o <br /> w <br /> - '----------------------------=---------- -=----- -----' <br /> � t I]' / - <br /> --- ----------- ----------------- -•-- ------ - ------- <br /> _t <br /> 4 <br /> Thereby certify'+ha+ I have-prepared this-application and'+iiat the work-will-be done in accordance with San Joaquin-County <br /> ordinances, State laws, and.rules and'regulations of the San Joarquin-Local Health District. <br /> - - F I <br /> _____ _ ____ _ - _ I --b <br /> (Signed).•------ - - -- - ---------- -------- f----- --------------�--- -'-------------------------------------------------------- --------(Owner and/or Contractor) <br /> Y• - --- -- --------- i'------------------------------------(Title)----------------------------------------------------- ----------- <br /> Bi <br /> (Plot plan, s owing size of lot, location of'system in relation to w!Is.�buildin s, etc., can be.placed on reverse side). ' <br /> °. FOR DEPARTMENT USE ONLY <br /> E. <br /> APPLICATION ACCEPTED BY----- -----------------------------------------------Z,;5 ------------------------ DATE-�------ � <br /> REVIEWED BY-=----------- ----------------------------= DATE - <br /> BUILDING PERMIT ISSUED------------------------------------------------ ------------- ------------...... --=-------------- DATE---------------------= <br /> -------------------------------------- <br /> Alterations and/or recommendations--------------------------------- ------- -0........... ::-__---------------------#----------------------------.­------------------------------------ <br /> -----------=--------------------------------------- - ------- -- --- ------------- ---- - - - ----- -------- - ------ <br /> �I <br /> -------------------1 _-_._lam_ _ ��_:� .. - --- �1- -�--�----- ----.--- -. -- _--------------------- ------------=-- <br /> ------------- ------ ---------- �t -mss ^� " f.--=------------------ -------------------=----- ------------------'----- --------------------------------- <br /> - ----------------------=----------------- --•----f------ .( <br /> ---------------------- --------------- <br /> ------------------------------------------------------------- ---- <br /> FINALpINSPECTION BY: -- =' - Date----------------------- <br /> --- '--------------------- --- <br /> 1 <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--21v1 Revised W-2100 l <br />