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FOR OF% E: 3 $ <br /> � 6- -- ------ - ._....... <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) y 2.4 1 <br /> ........................... .............. Date Issued __�..-..... . <br /> --------- ---------- 'This Permit Expires 1 Year'From Date'Issued <br /> Application is hereby made o the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in ompliance with County Ordinance No. 549/O lfieo oZ. FYM1 , <br /> ' JOB ADDRESS AND LOC ON................................�.:.....�.>.X....._L_.1(� Z ` 'C- <br /> Owner's Name..-.-.. - ...- + -� ............... ................ �'�.. .................... -d.................... Phone..'epwr� 7�5 <br /> Address........�......................i: c �..... - *' - 1- ...... <br /> ContrContractor's <br /> actor's Name. -----..'......... •----------------•--.....................:----..... .............i..._.............:... -- ----..... Phone................................... <br /> Installation will serve: Residence 5ff Apartment House❑ Commercial ❑ Trailer Court ❑ Motal ❑ Other ❑ <br /> Number of living uniis: .�..!. Number of bedrooms; ..'.` ... Number of baths �.,f.. Lot size .......,,2..t.:.�.1�.....�/....._��'._.y--:. <br /> Water Supply: Public'syst [j 1corrinri system ❑ Private [A'-Depth +o Wat Table .,71--dtt.' ` <br /> Character of soil to a depth of 3 feet: Sand C] Gravel ElSandy Loam IV' Clay Loam ❑ Clay ❑ Adobe E] Hardpan ❑ <br /> r <br /> Previous Application Made:'(if yes date...........,........) No go New Construction: Yes ❑ No E3 IPHA/VAt Yes No X1 <br /> TYPE OF INSTALLATION SAND SPECIFICATIONS: ( t 1 <br /> (No septic tank or cesspool permit+ed.if public sewer is available within 200 feet.) <br /> 1 r <br /> Septic Tank: i Distanc{I from nearest welL..aS^.Ct....Distance from foundation....: ...v_. ..Materiel... ... �^r''�----.. <br /> No. of''compartments....._...2..r..:------$ize9X.,�-)C--.� ...-.Liquid depth.....-y60e......_.---...Capacity_,op, -.-e-:- <br /> Disposal Field:, Distance from nearest well.. %:•Distance from foundation.,._ZC-�..--Distance to nearest-lo} line.....C. <br /> ' <br /> Numbel;of Imes......e Length of each'line..........:.�f` -`----Width.of`trench........._...:....... ... <br /> Type ofifilter material. C =:----Depth of filter material......�1} �_--Total length..._.......�..(�.cr._-`------ <br /> Seepage Pit: Distancto nearest well.............. .....Distance from foundation.--..................Distance to nearest lot line............. <br /> ❑ Numberof pits..... f-------.....Lining material.......................Size: Diameter.------------------ Depth .....-- ----.....:_....... <br /> I, t <br /> Cesspool: t Distance from nearest well................:Distance from foundation...............-- Lining material.._.............._........_...... <br /> ❑ - <br /> Size: Diameter....... -. . <br /> .... .. .. ...............Depth..............._2........•-- ---...Liquid Capacity..:.--'-----_---• ..................gals. <br /> ' i i w <br /> Privy: t Distance from nearest well--.-.>.:'. " ...........:.........._f..Distance from nearest building--........- <br /> ❑ _...:.�.t...- _-- . .... _ ,�- . _------•--..........................•_..........._..• <br /> Distanc�e to nearestlotline-----------------------`--------.......................... ....... <br /> Remodeling and/or repairing (describe):.._... .; .. <br /> 1 - - ....---�---- --------•------------`...................._......--•---.-...._..-------'- <br /> pp� .. _v.Q_'e�- -----''le............ ........................._-M� <br /> '-.--.......Y. i <br /> I <br /> . --------:.................................... .....-.......-...._............J-----j.....: ..e------- <br /> ' ...---------------------------. . .......................................--- ---K'-.-----...--------------`-- --------•------•-•----....i..-------------'---..................--------'•-•-------------- <br /> I hereby certify that llhave prepared this*application and that thei'work will be-done in accordance with San'Joaquin County <br /> ordinances, State laws, and rules and regul tions-of the'San Joaquin Local Health District. <br /> 1 { (Ow and/or Contractor) <br /> Si nod _. --- ....... - ......... (Owner <br /> By - �C (rtie)......... <br /> .................. <br /> (Plot plan, showing size of at, location of system in relation to we11s, buildings, etc.• earl placed on lieverse side). <br /> DEPARTMENT USE ONLY <br /> �� DATE....... <br /> - -�- <br /> APPLICATION ACCT PTE BY.. .... - ---> --� '[tom------'- --------------------------- . <br /> ' REVIEWED BY- - -- .................... ...................... --.....'.. -- - DATE...... .............. <br /> BUILDING PERMIT ItSUED----------------------- ------- ---------............._:.........................-----•-- <br /> DATE ...................---------------------------------- <br /> Altera on and/o recommends ns:-•_---.�..'.-r:.:...... -. <br /> ............................................................. <br /> ' 1 .... ........... .... -... _a. -.. ..-A.... .... .......r <br /> ----- ----"P.................. .......................... ... ....-----_...-- <br /> r� ........................ ....................................::........... <br /> .....�.......................... � ....fes r <br /> ' ........... - ..................._.-K....-- ..._- ..--- ---•-------�...._.•_..... __. .� ....'...-..----Date e--.. .. ........----------.---------.....--.....------- <br /> ✓ .. <br /> FINAL INSPECTION Bl..-.'... -- - (t(R- - - - - -- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Straet 300 West Oak Street 124 Sycamore Street 205 Wert 9th Street <br /> Stocktan,California Lodi,California Manteca,California Tracy,California <br /> ' ee•e YEVI9Ca 9-ee r.P.Ca.iM♦ ea _ <br />