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FOR OFFId USE: <br /> - 1 <br /> ..•--- --.. ........ . _ ..... <br /> APPLICATION FOR SANITATION PERMIT Permit No. . ..�?. . <br /> (Complete in Duplicate) �! J....- . <br /> _ Date Issue <br /> .................... ... This Permit Expires 1 Year From Date IssuedeT <br /> d .... . ,Cf. <br /> Application is 6reby 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. pf-- N ;q}S_ (�S - ' 7 <br /> JOB ADDRESS AND LO T! ...... ----- l` ' --- •• --... -------.. .. - <br /> Owners Namel�: .. C s_ -------------------- .................._._--------------•- Phone. <br /> Address..!V: .•-•-- -• •----- --•- ....-.....-................-----•............. <br /> A <br /> Contractor's Name............. Phone <br /> Installation willNserve: 'Reside Apartment House ❑ Commercial ❑ Trailer Court El Motel [3 Other <br /> Numbef of living units: .._._. Number of bedrooms;v Z. Number baths-t.... Lot size ...../_J-- ................................ <br /> Water Supply:. Public system ❑ Community system [3 Pr epth tii•Water Table ....._._ ft. t <br /> Character of IL it to a depth of 3 feet: - Sand❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe❑ Hardpan <br /> Previous Appliilation Made: (If yes,date. . .............) No ❑ New Construction: Yes [3-- No ❑ FHA/VA: Yes ❑ No <br /> TYPE,.OF INSTALLATION AND SPECIFICATIONS: r <br /> (No sop+ .) <br /> ic tank or cesspool permitted if public sewer is available within 200 feet <br /> r _ ,...�_r <br /> Septic Yank: Distance from nearest well...,`?'----..Distance�fr'om�fpundation..... .....Material.------- - ---•--•-- ,J <br /> No. of compartments. Size. .;Fr'... _.. sVLiquid depth.__.. -..t............ Capacity.... -4?,O.' <br /> Dispo Field:. Distance from nearest well_.__`► ..I Distance from foundation...... .. ...Distance to nearest lot {ine..?_- _.... 1 <br /> Number of lines............. Length of each line.3-," of french-------:Z,../ .........-._.. <br /> Type of filter material Depth of filter material_._._ ''v .Total len th...-._.. e?.�............... <br /> Seeps Pit: Distance to nearest well......�.f}. ......Distance Mf fo ndation.:.._.1. __._._.Distanle to nearest lot li ...--.Number of pits_.._.../.----------Lining material.--- ..Size: Diameter.... r Depth <br /> N <br /> Cesspool: Distance from nearest well.-...............Distance from foundation-:......-,__........Lining material__._............................. <br /> ..._ a f <br /> © Size: Diameter............................_.........Depth----•- ..--......i....Liquid Capacity---------------............gals. 3 <br /> Privy: Distance-from nearest well........... .....................................Distance from nearest building....................... <br /> ................... <br /> ❑ Distance to nearest lot line--------------------------------------....... .................. -------- ......................------.............................. SY <br /> Remodeling ' d/or repairing (describe):..................................................•-............................. ..----...............----.................._........_...•--.-••_. <br /> 1 i <br /> ii7 <br /> ---------------------------------------------- •---------...-••.....--••-•-•••-••-.....--•-•---...•-•-•-••-•---------•----•--------•-•-•---•........................................... . ...........................---..... ........ <br /> I hereby. ify that have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws rules and regulations of +he S n Joaquin Local Health District. <br /> (Signed) .... /y <br /> R ... ­and/or Contractor <br /> .� <br /> - - ----- <br /> (Plot plan, shoving slz of ot, lou ion of system in r lation to well ,buildings, etc., can be placed on reverse side). <br /> I� FOR DEPARTMENT USE ONLY �. <br /> APPLICATIONACCEPTED BY- . .. .... ... ----.... . .-.-.-..---•-- -------------••------•-------•-- - DATE-­?-:2' 0t7 3/-------------------- ----------- <br /> REVIEWEDBk-------•---•---:--•--•-............... ........- .....................-......._....... .._....: ..-•-- -••--•--•--•--.. DATE--------•----------......--.------------••----•----------•- <br /> BUILDING P RMIT ISSUED -------_..-------------------..-.... DATE ........... <br /> AlterationsJd/or recommendations:.............................................................................................................-...........................:................... <br /> ................- •-••-•..._...-.......----•.........................-•-•- ......................................................... <br /> I ................................. ...........................•----..............................................................• -•---•-•-•-•-••-••••. <br /> ...................... -.....-•---------------•-•...... ...... ------ ..-................---.............................._. ......................... ........... .............................................------... <br /> FINAL INSPECTION BY: . ....--- '.. ............. ._.-....... Dete.... ...t T -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 160 III E.Naseltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> stlktats,California Lodi,California Manteca,California Tracy,California <br /> 4 <br /> ES 9 AEVI$E I 9-58 3M 3-'63 F.P.CC. <br />