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FOR OFFICE USE: <br /> ---------------------------- - --------- ------------- <br /> APPLICATION FOR SANITATION PERMIT Permit No. ................. <br /> _------------------- <br /> (Complete-in Duplicate) <br /> 4 ----------- This Permit Ex Cres 1 Year From Date Issued Date Issued -----_1--�� <br /> Application 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 Ordinances No. 549.. <br /> JOB ADDRESS AND LOCATION.-_1 `- ` -- `�'�7 <br /> i4 Owner's Name-- - �? Phone--•---•--- •----....----•-••----•-•- <br /> - -----------------------•-------------- ------ --- _------- <br /> Address---------- -- "'7 ---`-------- - <br /> Contractor's Name-�-•- --- `----- ------- -----------------------•--•-- Phone_._.. <br /> Installation will serve: Residence - Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ,�„ <br /> Number of living units: --I---- Number of bedrooms __Number of baths --- Lot size ----- <br /> Wafer Supply: Public system ❑ Community system ❑ Private [''Depth to Water Table .rft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe "'Hardpan ❑ <br /> Previous Application Made: (If yes,date- ............. ) No E- New Construction: Yes ❑ No [I-- FHA/VA: Yes ❑ No [t <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septi Tank. Distance from nearest well-----------------Distance from foundation- ----------------.Material .................-........---------------------- <br /> � No. of compartments---- -------------------Size-------------------- ----------Liquid depth--------- ------- --- ---Capacity <br /> Disposal 'el Distance from nearest well. Distance from foundation_____.__.__.__..-.Distance to nearest lot liine_6 -------- <br /> LJ Number of lines--•------a-----------------------Length of each line__.. t1..r---------------.Wid#h of trench---- 4__.. -----------_---- \ <br /> Type of filter material._- --------Depth of filter material----l..f...........__.Total length------3,0___i_----------------------- O <br /> Seepage Pit: Distance to nearest well._.f�b_-_..._._Distance from foundation___________________.Distance to nearest lot line____- <br /> + [ff-_ Number of pits-.- -_ <br /> I---____._____Lining material___ _ . Size: Diameter.-.-__ --.----Depth-__:Z)_'_'------------- r <br /> t Cesspool: Distance from nearest well ________________Distance from foundation................. -,Lining material-------------------------------------- �-\I <br /> ElSize: Diameter- ------ ----------------Depth---------------------------------------------------•Liquid Capacity- -------------gals. <br /> E Privy: Distance from nearest well---------------------------------- --------------Distance from nearest building--------------....___.______---_______... <br /> C ❑ Distance to nearest lot line -------- --- --------- --------------------------- -------------------------------_------------ <br /> Remodeling and/or repairing jdescribe):._..0&_ ._ - _____._� ---- --- ---- --- -•- '- ' --- ---- <br /> D --------------------- --------------------------------- <br /> --------------------------------------------------- - <br /> k <br /> I hereby certify hat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ( ordinances, State I d rules and re ion of t San Joaquin Local Health District. <br /> Si ned ------------------------------- --------'-----•------- -- -- ---------------------------------- ------------------------ -------(Owner and/or Contractor) <br /> ( )•.--------- <br /> g <br /> By: --------- -------------------------------- -------------------------------- -------- --------------------- --------(Tif le)---------- ----- -------- --- --------- - - ------- --------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed an reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ,� -------------- DATE Y�=(- ----------- ----------------- <br /> REVIEWEDBY ---------------------------------- DATE--------- ------------------------------------------•------- <br /> BUILDING PERMIT ISSUED DATE ----------------------------------------------- <br /> Alterations and/or recommendations:....' '�!"? F�- - <br /> _----- - ---- ------ <br /> -------------------------------•--------- ---------------------------------------------------------------------------- ------- • ----- ----------------- ----------------------------------------------- <br /> ------------ -------- ----------------____------------ ------- -------------------- - -----------­------------- ................ ... ----------------- <br /> ------------- ....... ....... ----------I- --- --------/- ----------------­­----------- ------ ... ................­­­---------- <br /> FINAL <br /> ----------- ------------------------------ <br /> FINAL INSPECTION BY ---------------- Date-- _..... ----- -- <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 1601 E.fla:ellan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> 5lockton,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br /> f <br /> 4 <br />