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APPLICATION FOR SANITATION PER Permit No. <br /> (Complete in Duplicate) <br /> A A Date issued <br /> pplica+ion is hereby made f9 the San J :*A <br /> This application is made in compliance Joaquin Local Health District for a permit to construct and install the work herein described. <br /> with County Ordinance No. 54 <br /> JOB ADDRESS AOQ LOCATIO <br /> Owner *41' <br /> - <br /> sName.__ -- ----- ---------------------------------------------------------------------- <br /> dress..------ 0 -------------- <br /> 1;0C- --------- -------------- --------- -- Phone------ <br /> ---- ----- ----------------- <br /> ---- --------------------------------------------------------------- --------------- .... <br /> Contractor's Name.... <br /> 0.1 <br /> ------- --- <br /> - <br /> ---------------------------------------------- <br /> -------------------------------------------- <br /> Installation'will serve: Residence E4.44"ment House 0 <br /> Number of living units: Number of bedrooms Commercial Ll Trailer Court C] Motel 0 Other 0 <br /> Wafer Supply: Public system /__ _V_ Number ❑ <br /> of baths /----- Lot size ----4-dr <br /> 4--almmunify system Ej Private - I <br /> ED Depth to Water Table 4--off. <br /> Character of soil to a depth of 3 Clay Loam feet: Sand 0 Gravel Ej Sandy Loam [D [3 Clay El Adobe�A�aldpan Ej <br /> Previous Application Made: Yes El No Construction: Yes EJ No 0%... <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Se ti Tank; <br /> �Sefi Tank: Distance from nearest well------------- Distance from foundation <br /> _--_--- <br /> '6 <br /> No, of compartments-_ ------ ---Size--- -----..Material------------------- <br /> Material-------------- ---- -------------------- <br /> "p, <br /> -------------I-------------Liquid depth --------- <br /> ---------------- <br /> . ........Capacity <br /> ;sposal Fiel Distance from nearest well-------------- D'sfance from foundation___________________Distance <br /> ............... <br /> Number of lines------------- --------------------Distance to nearest lot <br /> Type 07' filter material----------------------- ----Length of each line---------------------- ------Width of frenc line__.___------___-- <br /> 0material--------------- <br /> _h----------------------------------- <br /> ---------------Depth if filter material---- --------__---Total length <br /> Seepage"Pit: Distance to nearest welANS-Tril,------D'stanc om fo ridation ------------------------------------------ <br /> Number of pits___-. I _-----_---Lining material-- t 10 ---4--!q------Distance to near6s7-[-o-f-jlire__ <br /> Cesspool:. �anca from I m nearest well ��a----Size: Diameter_-V&----- ----- <br /> Dept' <br /> L <br /> 0 Size: Diameter -----------------Disfance from foundation,:__----- <br /> -------------- ------------ --------Depth------ ----._ __-Lining material------ _"_� _j--------- <br /> Privy: ------------------------ ---------------------Liquid Capacity ------- <br /> Disfante from nearest well------------- ___-__Distance- from nearest building------..................----.______gals <br /> El Distance to nearest lot line------------------ <br /> Remodelingand/or repairing (describe)--------------------------------­----- --------------:--------------------------------------------------------- ---------- --------------- --------------------- <br /> --------------------------- ------------------------------------------------------------- ------------------------------------------------------------------------------------ ------------------------ <br /> ---------------------------- ------------------- -------•---•----•---------------•----------------------------------------------- <br /> --------------_-------------- --- ----------------------------------------------_------------------------------- --- .1 <br /> -- - - ii - - -------- -- ----------- - ----- ---- - ------ - - ---- -- <br /> I hereby certify that I have prepared This application and that the work __J_o_a`qu_in------------ - <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. County <br /> (Signed)---- <br /> By:.- relation to wells, buildings, etc., - F-MfwContract <br /> (Plot plan, Aiding or) <br /> -o-,f- sys -----(Title)------------------------------------------------ <br /> can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..-_________________- <br /> --- <br /> REVIEWED BY ------------------------------ DATE_.----- <br /> BUIL ------------------ -------------------------------------- .... - ----- <br /> DATE------- <br /> DING <br /> ---- <br /> DATE------- <br /> - <br /> -----------------D--1-1I--N------G-----------P----E----R----M-------I--T-----------------------E-(_-'-.----- --- ---------------:-�---------------------------------------7.-...- .N.-. <br /> ------ ---_-_-­:-_----_------------------------- <br /> ----------- <br /> ------ <br /> ---------------------------------------­-D-----A-----IT----EAlterations and/or recommendations:__-.__.____ <br /> ---- <br /> ------------------------------------- <br /> -------\----`----.'---------------------------------------- ------ <br /> -----------------------------._S- ------------------------------ - - - <br /> --- 1 - ,- r ------------------ <br /> - <br /> - <br /> - <br /> --------------------------------------------*----------------------------------------------------------- <br /> ------- -------------------------------- -------- ---Q­------ --------------- ----------------------- ------- ---------------------------------------------------------- <br /> --------- <br /> FINAL INSPECTION BY:._..-_. <br /> Date---- <br /> SAN <br /> ate....SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street <br /> Sfockfo", California Lodi, California <br /> Manteca, California Tracy, California <br /> ES-9-2m <br />