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APPLICATION FOR SANITATION PERMIT Permit <br /> (Complete in Duplicate) <br /> Date Issued - /'�/� 3__.�/ <br /> App!lic�aiXs�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------------- ------- <br /> -------7�---T_��---------------------------------------------------------------------------------------- <br /> Owner's Name----------------------------------------------G-hen_----lenMM----------------------------------------------------------- Phone-44-C-5- ----- <br /> Address---------------------------------------------------------- <br /> Contractor's Name---------------------------------- <br /> Installation will serve: Residence-g Apartment House ❑ Commercial E] Trailer Court E] Motel 1-1 Other El <br /> Number of living units: _/--- Number of bedrooms _ff_ Number of baths j--- Lot size ----01-p-_J------- ----------------- <br /> Water Supply: Public system t9 Community system E-1 Private E] Depth to Water Table,;P-9 ftA-, <br /> Character of soil to a depth of 3 feet: Sand E] Gravel Ej Sandy Loam E] Clay Loam 0 Clay 0 Adobe Hardpan E] <br /> Previous Application Made: Yes E] No X New Construction: Yes El No E]�,ZYY24'�' Oj <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> pfic Tank: Distance from nearest we!!_________________Distance from foundation--------------------Material------------------------------------------------ <br /> No. of compartments--------------------------Size------------ ------------------Liquid depth--------------------------Capacity-,--------------------- <br /> Disposal Field: Distance from nearest well Distance from foundat;on.157-_________Distance to nearest lot line-----�_6 <br /> 19 Number of lines-------- Arcrx__ -----Length of each line___2_C-----------------Width of trench-,-)_*_*1--------------------- <br /> Type <br /> 1----- ------ <br /> Type of filter materia!__ ------A-K.Depth of filter material------ ---Total length-.2-0--------------------- <br /> Seepage Pit; Distance to nearest weii__*�,nil?-------D;sfanc ,from foundation_..founclation-Y.-57- __Distance to nearest 10 1- e___/---i__` <br /> Number of pifs-----/-------------Lining material --------------4_--Size: Diameter-__----A- 1- Dept h- <br /> ----- -- -------I-------------- <br /> Cesspool: Distance from nearest well------- --------Distance f m foundation--------------------Lining material--_-_-______________________________ <br /> E] =Size:-Diameter Dept -------------------------- ---Liqu id,.Ca pacify--_-___.gals. <br /> Privy: Distance from nearest - -- - -Distance to nearest lot line well_________________________ -- -- <br /> --- -------Distance from nearest building------------------------------------- <br /> El ------ ---- --------------------- ----- <br /> Remodeling and/or repairing (describe) -- <br /> : <br /> ------------------------ <br /> -.1 ----- 4----- - <br /> ; <br /> - -----------------------------------------I--,----*-,------I------------------------- <br /> ---------------------------------............ ----------------------------------0/11 .- - 4/-------00------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------ ---------------------------------- ------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> - -----I—------------------------------------ <br /> I hereby certify that I have-prVared this application and that +he work will be done in accordance with San Joaquin County <br /> ordinances, Sttaf laws, a rules and regulations of Joaqin_Local-lzlealfh District. <br /> s 1-�C_ <br /> (Signed), -------- -PA ----------------------------- ----------------------(owmi'an*W Contractor) <br /> ---------- <br /> By:------------- --------- ---- --- - -- ----------------------------------------------------------------------(Title)----- <br /> . 4) <br /> (Plot plan, show" ng size of lot, locaflon ofysfe buildings, etc., can be placed on reverse side). <br /> m in relation to wells, <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------ - ------------ --------------------------------------- DATE------- <br /> REVIEWEDBY----------------------------------------------------- --- --------------------------- ---------------------------------------- DATE----------- —-------- <br /> ------------------------------------- <br /> BUILDINGPERMIT ISSUED---------------------------------------------------- ------------------------------------------------- DATE------------------------------------------------------------ <br /> Alterations and/or recommendations:-----------------------------------------------------------------------------_-----------r-----------------------------------------------­-------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------­­-------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------- ---- ----------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- -------------------------I----------------------------------------- ------------------------------------------------------------------------------------------------- ------- <br /> FINAL r INSPECTION BY: ----------------------------------- Date------------7141;�711 --:--------------- <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 />