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FOR OFFICE USE: - <br /> ------------------- ------------•------------------------ / / f <br /> APPLICATION FOR SANITATION PERMIT Permit No. .., .GP_((1.r1 <br /> --- ------. (Complete in Duplicated # <br /> /1 <br /> Date Issued <br /> ....................... <br /> ...... ................. . ------- This Permit Expires 1 Year From Date Issued � "7 <br /> tq <br /> -Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein escribed. <br /> This application is made in compliance with County Ordinance No. 549. <br /> `-JOIB ADDRESS AND LOCATION--- , _. _ - --------L------- ..... ._d7L_ !k - -------- <br /> Owner's Name Phone------ =------- <br /> Address---------yz•2---e-:---- ------- - --•-•------ ------------------- ------------------------------------`------------------------_--- ..... ------------.------ <br /> Contractor's Name Phone ----------••-•------------- <br /> Installation will serve: Residence ��Apartment House ❑ Commercial E] Trailer Court [-] Motel ❑ Cthb r ❑ <br /> Number of living units:.-_ ___, Number of=bedrooms _2,Number.of baths j---- Lot size _-4,1'aa._ __ _____ __ _________________________ <br /> Water Supply: Public system Community system [I Private Depth to Water Tablft. <br /> Character of soil to a depth of 3 feet: Sand Grave! Sand Loam Clay Loam Clay Adobe Hardpan <br /> P � ❑ Y ❑ Y ❑ Y ❑ ❑ ❑ <br /> Previous Application Made: (If yes,date------_------------) No [g�' New Construction: Yes P�t—No ❑ HtA/VA..Yes [] No _ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: 4 1 <br /> (No septic tank or cesspool permitted if ublic sewer is available within 200 feet.) [ <br /> _=Distance from fou dat'son1_ --_----._Material --------------- <br /> Septic nk: Distance from nearest well.4"" <br /> ____.. �____ Material-'p <br /> No. of compartments----•Z_-------------_---Size----_�:�_a_�X7-____Liquid depth-___ .�----'!�__�_'Capacify.. 0 <br /> Msposal ld: Distance from nearest weil�.-11.--Distance fromfoundation-_� �..r_______.Distance to`earest of I ne___._______�-- <br /> �. . <br /> Number of lines__ __ ______________Length of each line'____ ---------------.Width of trench._.._ _��_�__.__. ------------ <br /> ------ Ii �^ <br /> Type of filter material___-"__1?C__�'____-Depth of filter,maferial--- <br /> l ,--____------Total length_-_----- ____-------------------- <br /> Seepage <br /> ----------------- v! <br /> f <br /> ❑ Number of nearest well_t_ _________________Distance from:foundation--------.---------- Distance to nearest lot line----- <br /> --Seepage Pit: Distance to pits----------------------Lining material--------.-.__---�--...Size: Diameter------------------------Dept h------��----�--------------_-. <br /> I <br /> Cesspool: Distance from nearest welL________________Distance from foundation--------------------Lining material---------------- <br /> Size: Diameter-------------------------- -- <br /> -------- -De th--------------- - <br /> -------- ---------------------- <br /> ❑ p -Liquid Capacity------iJ----------------..gals.i <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------ <br /> ----_______..-___.. <br /> ❑ Distance to nearest lot line------- -------------------------------------------------------------------------------------------- ----- <br /> Remodeling and/or repairing (describe)------------------------------------ <br /> ------------------ <br /> ------------____--------_------- __________ _--_-__.__---------- <br /> 0. ( <br /> ________________________________________________________________________________________________________________________ <br /> ii <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 re ations the San Joaquin Local Health District. <br /> (Signed)---------------- -------------------•-aion <br /> ---------- - - ------------------------ -------�-—--------- --- -----'..--�" —(Owner and/or Contractor) .�.. <br /> BY:--------------------------------- -- ---- - -- ------------=-.-----------------------------------------(Title)--------------------•------ - - - ---- <br /> (Plot plan, showing size of lot, ystem in .elation to wells, buildings, etc., can be placed on reverse sid ). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- .. r- .t------- --------------------------------- ------------------------- DATE-------Z/­-__:x1-f77-;61_�3-----•-----•----- <br /> REVIEWEDBY----- --------------------------------------- ----------------------------------------•------------------------------•-------- DATE-------------•----------------1-T------------•------------ <br /> BUILDING PERMIT ISSUED-------------------------------------------------- •---------•------------------•------------------- DATE------------------------------- I <br /> Alterations and/or recommendations----------- -------------------------------------------------------------------------------------•-•------------------------------- ------------------------- <br /> I <br /> ------------------------------- <br /> ------- <br /> ----- ---------- ------------ ---------------------------------------------------------------------------•--------------- ------°---------------------------- <br /> -------------------------------- <br /> I <br /> FINAL INSPE BY ------- � Date. 2Z' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> I <br /> Slocklon,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REVISED B-59 3M 3•163 F.P.CO. <br /> 5' <br />