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t a 1<4411� . 41-Y-A4 <br /> APPLICATION FOR SANITATION PERMIT Permit No -------- <br /> (Complete in Duplicate) <br /> A Date Issued <br /> I ton is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> Thit application is made in compliance with County Ordinance No. 549. �� O� <br /> ZS—7�5-1 <br /> JOB ADDRESS ANOCATIC;N,��_;� ------------ ------- -------------------- <br /> Owner's Name-----6A --------- ---- - ------------------ -------------­ Phone----------------------------------- <br /> T_ - - --- - - -------------------------- ------ <br /> Address------------- ---- -- --- -----Z&6z------n ­----------------------------------------------------------------------------------------------- <br /> Contractor's Name------------ --------------------------------------------------------------------------/------------- ------------------- ---------------- Phone----------------------------------- <br /> Installation will serve: Residence F1 Apartment House 0 Commercial Iwrailer Court E] Motel C] Other E] <br /> Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size -------------------------------------------------------- <br /> Water Supply: Public system 0 Community system [I Private F1 Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand [] Gravel F1 Sandy Loam E] Clay Loam Ej Clay Ej Adobe❑ Hardpan F] <br /> Previous Application Made: Yes El No F] New Construction: Yes El No 1:1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.)-. <br /> 7 <br /> Material----------------------- <br /> Septic Tank? Distance from nearest well-----------------Distance from foundation------------------ -------------------------- <br /> El Na. of compartments-------------- ---:-------Size--------------------------- Liquid depth-------------- -----------Capacity----------7:.......... <br /> I <br /> Disposal ield: Distance from nearest well-_- ------Distance from founclafion.-_Z�-6-t-'---.-.Distance to nearest lot line--;-e) vo <br /> ------------- <br /> Number 0.1 lines------------/---------------------Length of each line---------fes ------i----Width of trench----!.K.a--------------------- --j <br /> rlength------/0— A <br /> Type OT filter material-- ---Depth of filter material--------- Total -------------------- <br /> _r---------------- <br /> Seepage Pit: Distance to nearest well-.--------------------Distance from foundation-------------------Distance-fo nearest lot line..----.-------1 <br /> 0 Number of pits----------------------Lining material-------------- --------Size: Diameter.----------------------Depth.--------------------:----------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--- ----------------Lining material--------.-----_.-------____._-_---- <br /> ElSize: Diameter---- --------------------------------Depth----------------------------- ---------------------_Li quid Capacity----------------------------gals <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------- ------------------ --- <br /> ElDistance to nearest lot line------------------------ -----------------------------------------------------------------------------�--.------------------------------------- <br /> Remodeli and/or repairing (clescribei: --7- <br /> ----------- ­ -'r------11,1- <br /> '----A�_t <br /> - x . ---------------- ---------------------- ---------------------------------------------------------------------------- <br /> -------------------------------V-------------------------------------------------------------------------------------------------------------------------------------------­­--------------------------------- <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, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)----------------- -- -- -- --------------------------------------------------------------------------------- ---------------------------------------------(Owner and/or Contractor) <br /> -- --------------- ----------------------------------------------------- <br /> By---------- ------------------(Title)-------------------------------------------- - ---------------- <br /> (Plot plan, showing sae of lot, 10 on of system in relation to-wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-..-. ---------- - ----------- ------I---------------------------------------- DATL:� <br /> REVIEWEDBY----------------------------------- ----------7-------- - DAT .. . ---- -------------------------------------------------------- ---------- <br /> BUILDINGPERMIT ISSUED-------------------------------- ---------------------------------------- ------------------------ DATE--------------------•------------.0—--------------------- <br /> Alterations and/or recommendations:_-------------------- -- -------------------------------------------------------------------------------------------------- -------------------------------- <br /> -----------------------------------------------------------------1--------------------------------------------------------------------------------------------------------I------------------------------------------------- <br /> ----------­----------------------1---------------------------------------------------------------------- ----------------------------------------------------------- ---------------- ------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------­-­--------------------------------- ---------­------ ----------------- <br /> - ------------------------- ------------------------------------------ --------- ---------------------- --------------------- ----------------------------------------------- ------------------------------------------------ <br /> FINAL INSPECTION BY:___,,�_ -- ---- -------------------- Date l -------------------------------------------- <br /> SAN JOAQUIN LOCAL HEA DISTRIC <br /> a <br /> 130 South American Street 300 West Oak Street 702 Sycamore Street 814 North "C" Street <br /> - Street <br /> a ac., California Tracy, California <br /> Sfocic+on, California Lodi, California Manteca, Caiifornia <br /> ES-9-2M 10-52 Revised W-2100 <br />