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4 <br /> APPLICATION FOR SANITATION PERMIT Parmit N6.,;? _ _ ---- <br /> (Complete in Duplicate) `r <br /> 1 - <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 /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION -- --�° �� = _AL' `J--------------------------,-----------------------------------------------=---- <br /> Owner's Nameye ----------- <br /> -- Phone <br /> Address-------- ) ---------------•------------------------------------------------------------------ <br /> - -- -- --- ---- ------------- <br /> Contractor's Name--------- --- --- ---------- Phone------------------ ------------------ <br /> Installation will serve: Residence ©'artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---L Number of bedrooms .,L- Number of baths __4___ Lot size ----� X--3_�-Q------------------------ <br /> Water Supply: Public system ❑ Community system -E-1Private [Depth to Water Table -------- ft. <br /> Sand Gravel E] Sandy Loam F1Clay Loam El Clay E] Adobe He <br /> depth of 3 feet: San <br /> Character of soil to a p rdpan E]} ❑ <br /> Previous Application Made: Yes ❑ No 12/ New Construction: Yes eNo ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if.public sewer is available within 200 feet.) <br /> Septic an Distance from nearest well-----------------Distance from foundation-------------------.Material________------___-----_________--_---------_ <br /> No. of compartments--- ------- -------- ---Size----------------- Liquid de t Capacity ; = <br /> Dis os el. : Distance from nearest we __ e __-_--Distance from foundation _�/. <br /> Distance to nearest lot <br /> pi------- --- <br /> Number of fines--`--------- -- -- -------- Length of each line--____-_ - f( ----Width of trench___-- <br /> Type of filter materi _i A epth of filter material-_____C_ _________Total length________-_ <br /> f---------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line_____------___.-_ <br /> ❑ Number of pits----------------------Lining material---------_-----------Size: Diameter------------------------Depth-------------------------------- <br /> Cesspool: Distance from nearest well_______________ Distance from foundation-------------------.Lining material____ _---______--_____ _a--_ <br /> ----�- ------------------------------ <br /> ❑ Size: DiameterDepth----------------------------------------- <br /> -- ----Liquid Capacity-------------- ------- <br /> --•--gls <br /> i <br /> Privy: Distance from nea:, rest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> ❑ Distance to nearest lot line-------------------------------------------- ------------------------------------------------------------------------------------------------ <br /> Remodeling and/or repairing (describe):_ ------------------- --------------------------------•------------------------------------------------------------------------- <br /> ---------------------- <br /> --------------------------------------------­­--------------------------------------------------------------------------------------- <br /> = = ----------------------------------------------------------------------------------------------•-------------------------- <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, 5# a laws, an rules and regulations of the San Joaquin Local Health District. <br /> (Signed]____ __,_ <br /> ` ----------------(Owner and/or Contractor] <br /> -------------------------- <br /> ---------------------------------------------- <br /> (Plot <br /> -- ----------------- - ------ Title <br /> - -- - - - ------------------------------------ <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLYI <br /> APPLICATION ACCEPTED BYC_._ <br /> ��yy -------------------------------- DATE - -------------------------------------- 1� <br /> - __- _--------------------------------------------------- <br /> -------- <br /> DATE <br /> REVIEWED BY---•--------------------------- - <br /> BUILDINGPERMIT ISSUED--------------------------------------------------------- ------------------------------------------- DATE yo <br /> and/or recommendations------------------------------------------ ------ -------- <br /> -------------------------------- <br /> ----------- - <br /> - Z----- <br /> -___r_ <br /> / <br /> ------------- -------------------- ` ' = _,R <br /> ---------------------------------- <br /> ------------------------ <br /> ----------------------------------------------------- <br /> -------- ----- ---------------------------- <br /> --------------------- IF <br /> 0 ----------------- ------------------- <br /> FINAL INSPECTION BY_ '__ <br /> Date------- --------•------------- --------- <br /> I <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT 4 v D- f S b <br /> 130 South American Street 300 West Oak S+reet 132 Sycamore-Sfree+ 814 North "C" Street <br /> S+ockfon, California Lodi, California Manteca, California Tracy. California <br /> ES---9-2M 8-51 Revised W-2100 <br />