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%FOR OFFICE USE: I - <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> -------------- ------ ----------------------------------- <br /> ------------------- -------:-,,z---------- <br /> (Complete in Duplicate) Date Issued <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued A_Iz� <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—�r ------------ <br /> Owne'r's Name------ , <br /> ame-----4 ,—--- -----46 4-16or"----------------------------------------------------------------------------------------- Phone-------------------------------------- <br /> Address-------- <br /> .. ....aya-". -t#' <br /> - - --------------------------------------- <br /> --------- --------------------------------------------------------------------------------------------------------------- <br /> Contractor's -----....--------------- <br /> ----- ---------------­-----I------------------------------------------------------------------ Phone----------------------------------- <br /> Installation will serve: Residence Apartment House 0 Commercial Ej, Trailer Court E] Motel E] Other E] <br /> Number of living units. ----- Number of bedrooms Number of baths __.)---- Lot size 1-Ift-ki-q-50------------------------------------ <br /> Water. Supply: Public'system El Community system El Private a] Depth to Wafer Table 1r___ ft. <br /> Character of soil to a depth of 3 fee+: Sand F_] Gravel E] Sandy Loam El Clay Loam Clay.[] Adobe jE Hardpan C] <br /> Previous Application Made: (If yes,date--------------------) No � New Construction: Yes ] No ❑ PHA/VA: Yes L] No 0 <br /> TYPE OF INSTALLATION AND SPEC I Fir-ATIONS:.— <br /> ed.if public sewer is available within 200 feet.) <br /> t (No septic tank cesspool <br /> permitted.. <br /> Septic Tank: Distance nearest well---------------------bis'*ce from foundation___________________Material--__-________._.__________.____.______.._-_____.No. of compartments--------------------------Size--------------------------------Liquid depth_____._,:------------------ Ca pacify------------------------ <br /> Disposal Field: Distance from nearest weil-------------------Distance from foundation---_--------------Distance to nearest lot line______'_______.-. <br /> Number <br /> ine----------------- <br /> Nu'mber of lines-Ll- ------------Length of each line-----------------------------Width of trench.----_-------_------_-------------- <br /> ---------------------- <br /> Tye of filfer 4aferial-------------------------Depth of filter material-----------------------Total length----------------------------------------- <br /> p <br /> she Pit- Distance to near'esf ----------Distance fro founclafion--P-A............ Distance to nearest lot line§�---------- <br /> T <br /> 1, 14/ <br /> Number of pifs- .-A --------Lining material-r.- -....-,---_Size: DiamefedIP_'JV__1_P........D,ptk-.-..f-------------------------- is- <br /> Cesspool: Distance from nearest well-'--__, ---Distance from foundation___ --------- -- Lining material__-----._.___.____________________ <br /> ---------------- -----Size: Diameter--- Depth----------------------------------------------------Li uid Capacity------------------------.---gals <br /> Privy:' Distance from nearest W611------------------- -----------------------------Disfance from nearest building---_---_____________________-_--___-_.__. <br /> " <br /> ❑ <br /> Distance to nearest lot line-------------------------------------------------------------------------------I <br /> Remodeling and/or repairing (describe):------------------------------------ ----------- ----------------- ------------------------------------------------------------------------- <br /> ---------------I-------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------- <br /> --------------------------------------------------------------j-------------------------------------------------------------------------------------I---------------------------------------------------------------- <br /> -----------------------------------------------------------------a--------------------------------I----------------------------------------------------------------------:---------------------------------------------------------- <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' �TrJ <br /> -- --------- <br /> -------------- ----------------------------------- -------------------------- - _{Owner 'and/or Contractor) <br /> t <br /> 4 13T._,�_. -------- <br /> - - - <br /> -- ---------------------------------------------------------------------------------------------------- ---- ---------------------------- - ------------ ------ ---------- <br /> (Plot pllan,.showir�g size of lot, location of system in relation to wells, buildings,efc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ------------- ------------------------------------------------ DATE__?_-3 - <br /> REVIEWED BY----------------------------- ----------- --------------------- --------------------------------I-------------------------- DATE = <br /> IF <br /> BUILDINGPERMIT ISSUED------------- -------------------- -----------------------------------------------------------------.. DATE--------- - ------------------------------------------------- <br /> Alterations and/or recommendaf ions-.* ---- - - ------ <br /> ----------------------­------------------------------------------------------------------------------------------------------------- <br /> -------------I-------------------------------------------------------- --------------------------------------------------------------------------------------------- --------------------------------------------------------- <br /> ---------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------ ---------------------------------------- ----------- ------------------- -----------------------------------------------------------------------I-------------------------------------- <br /> ------ ----------- ----- ------ ---- ----------------------------- - ------- ------- --------------- ---------- ------------------------------------------------------------FINAL INSPECT'ION' B Y - - ------- ---------------------- Date--- ------------------ ------ --------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �1601 E.Haxelloti-Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Sfockfan,California Lodi,California Manteca,California Tracy,California <br /> rs 9 REVISEL 9-59 3M 3-*6:1 IP.Pmo. <br />