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APPLICATION FOR*..ANITATION PERMII-i-.o Permit No. _Jo_y`7... <br /> 1n� (Complete in Duplicate) <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> 'his application is made in compliance with County Ordinance No. 54�- <br /> JOB ADDRESS A D LOCATION-r------ ''`-- ----------------------------------------------------------------------------------------- <br /> �. >lQOwner's Name---- "!N-_ 1 <br /> ------ <br /> ----------- ----------------------- <br /> Address-----`d� -� <br /> Contractor's Name ----- -- ------ ---------------------­------ <br /> 4 � ?��� ClC� -------------- Phone.Yl 0.1- T-�9--'' <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court -❑ Motel ❑ Other ❑ <br /> Number of living units: -- -- Number of bedrooms 1_-- Number of baths'__--_- Lot size -----,�0___JL-_-1_�'_6?------------------------------ <br /> Water Supply: Public system M Community system ❑ Private ❑ Depth to Water Table _4/_,�"ft. 4 <br /> Character of soil to a depth of 3-feet: Sand ❑ Gravei ❑ Sandy Loam E❑ Clay Loam ❑ Clay ❑ Adobe R] Hardpan ❑ <br /> Previous Application Made: Yes C. No ❑ New Construction. Yes X No ❑ -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 /> p i k': Distance from nearest well-----------------Distance from foundation------__--_----___.Material---------------_----_----------__-____---------. <br /> No. of compartments------- ------ ----- -----Size--------------------------------Liquid depth--------------------------Capacity-•--------------------- <br /> Disposa ield: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line--------__------- <br /> Number of lines-----------------------------------Length of each line--------_---------------------Width of trench-----------------•----------------- <br /> Type of filter material-------------- -------Depth of filter material-'---------------- ----Total length------------------------------------------ <br /> Seepage Pit: Distance to nearest well--- "_ --_-Distance from f undation__---1 ..,--.Distance to nearest lot line---&---------- <br /> Number of pits--- ... ----Lining material---'��-- ,-...Size: Diameter----5--._'�_----------Depth---------e -------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------.-----Lining material------------------------------------- <br /> El Size: Diameter-------------------------- -----------Depth-------------------------------`------ -------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well----1--------------------------------------------Distance from nearest building___--.----------------___-------_-----.-. <br /> ❑ Distance to nearest lot lire <br /> Remodeling and or repairing describe :__-- ' <br /> ---•----------------------------------------------------------------------------=----- ---------------------------------------------------- <br /> ------------------------------•-----------------------------•---- <br /> f --------------------------------------------------------------------------------------------------=--_--------------------------------------------------------------------------•---------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> r (Signed)- '------- -------------------------------------------(Owner and/or Contractor) <br />' Sy:---=-• -- -------- =--------------------------------------------------------------------(Title) - --------------------------- <br /> l <br /> (Plot plan, s owing sif lot, location of system in relation to wells, buildings, etc., can be placed on revers side). <br /> FOR DEPARTMENT USE ONLY t <br /> i <br /> APPLICATION ACCEPTED BY------- -- - ---------------------------------------------- DATE-•----- <br /> f REVIEWED BY------------------------- ---- ------------ -- ------------------------- DATE----- <br /> BUILDING PEROT ISSUED-------------------------------------------------------------------------------------------- DATE <br /> Alterations and/or recommendations:-__--------------------- <br /> 11 <br /> - == =------------- ---------------`------------------------------------------_----=---=--• "------- ---------- <br /> -------------- <br /> F ---------------------------------------------------------------------------------------------------- <br /> ---------------------•- -----�--------------------------•----•--•---------- ------------- --------------------------------------- <br /> r,FINAL INSPECTION BY:. ---- -- -- ---------------- Date- l______-- .3 Q <br />€ t.� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lcidi,.,California Manteca, California Tracy, California <br /> �'- ES-4-2M , Revises 1-57 F,P,CO. <br />