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FOR OFFICE USE: <br /> -------------------------------------------------- ------ <br /> APPLICATION FOR SANITATION PEP-MIT Permit No. <br /> ------------ --- - -- --- -7 <br /> (Complete in Duplicate) Date Issued <br /> ----------- -- -- --------- - - <br /> ------------------------------------ This Permit Expires 1. Year From Date Issued <br /> Application is.herbby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compZln-to with C u f Ordinance No. 549. <br /> 11V .-W , nx <br /> 'LOCATION___iLq -V <br /> JOB ADDRESS AND ------ ---------------_----- <br /> f------------ <br /> Phone__'-------------------­- <br /> Owner's Name--- ..... -----------VQ <br /> Address--.----J Ovj g ....... <br /> --------------------------------------------------------------------------- <br /> -------------- ------------------ <br /> Contractor's Name.. ,4_4: 6Y ------------------------------------------------------ <br /> ----------------------------- ------------- Phone--_------------------------- <br /> '1 --------- <br /> Installation will serve: Residence Apartment House ❑ Commercial [] Trailer -Court ❑ Motel [j Other El <br /> -Number of baths --.7- Lot size of living units: -0-14- Number of bedrooms --- _7 <br /> Community system El private Depth to Water TabIJV/_?:,ff. <br /> Wafer Supply: Public system 011.1 <br /> Character of soil to a depth of 3 feet: : Sand E-] Gravel E] Sandy Loam [] Clay Loam F Clay ❑ Adobe Hardpan 0 <br /> J_EfPrevious Application Made: (If yes,date.--,-------:--------) N o)ff New Construction. Yes El NQ � FHA/VA: Yes E] N oM <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No SGpfiC tank or cesspool permitted if public sewer is available within 200 feet.) <br /> r ----------- <br /> Septic Tank. Distance from nearest well----___________Distance from.foundation--------------------Material---------------------- --------------- <br /> • <br /> ----------- <br /> No. of compartments--------------------- ----Size--------------------------------Liquid depth---------------------------------------------r-Capacity-------- <br /> tion------ nearest lot line--- <br /> Disposal Field:- Distance from nearest well___ ___.._____Distance from founc18 Z-1) -/------Distance to r -------- <br /> Number of lines------/--------------------------Length of each line-----------------------------Width of french__ ---------- <br /> ngth-------- -------------------------- <br /> Jype of filter material_�;j �_715�&Depth of filter material-'--- ----------Total le <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation__.----------------rDisfance to nearest lot line______ __..--_._ <br /> ❑ <br /> ine------N Number of pits-----------------------Lining material---------------------- Size- Diameter._.-___-_._._..._ Depth---------------------------------V <br /> Cesspool: Distance from nearest well-----------------Distance from foundation----- - -------------Lining material____.._______-_--------------_---- <br /> 'A ----- ----gal;❑ . <br /> Size: Diameter___----------------------------------Depth--------------------------------- -----------------Liquid Capacity----------------- <br /> _77 7 <br /> Distance ---- from nearest(building_ ------------------ <br /> Privy- e from nearest well----------------------------------- -__.___._Distance f ------- <br /> 0 Dis:tance to nearest lot line-- --------------------------------------------------------------------------------------------- --------------------------- ----------------- <br /> --------------- <br /> Remodeling and/or repairing (describe):--------------------------I------- ------------------------------------------------------------------------------- ------------------------ <br /> % I ------------•--------------------------------------- --------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------- --------------- <br /> ------------------------------ ------------ ---------------- -----------------------------------------------------------_ <br /> --------------- I <br /> - --------------- - <br /> --------------------------I------------------------------------------------------------------------------------------ ----- <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 /> 4-), -------------------- --------------------------(Owner and/or 'Contractor) <br /> ------------------------------------------------------ <br /> ---------- -------------- ------------- - --------------- <br /> ------------ -------------------------------------------------------------------------------------------(Title) <br /> (Plot plan, showing size of lot, loca'Vion of system in relation'to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> DATE_•------------- ------- -------------------- <br /> ACCEPTED'BY <br /> REVIEWEDBY--------------------------------------------------------------------------------- -------D------------------ DATE------�7__ <br /> BUILDINGPERMIT ISSUED--------------------------- ...........---------- DATE------ --------------------------- ---------I----------------- <br /> Alterationsand/or_recommenidafions:-------------- ------------------------------------------------------------------------------------------------------------------------------ ------------------- <br /> --------------------------- ---------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------- <br /> --------­-------------- --------------------------- -- - ------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 11 ----------------------------------------------------------------- ----------------• -------- <br /> -------------------- ---------------- ------------------------ --------------------------------------- ----------w�---7 <br /> ----------------- ------------------------------ ------ - ---------------------------------I------------------------------------------------- ------------------------------------------------------------------------------ <br /> ------------------------------------------------ <br /> FINAL INSPECTION BY:.---------- Date----------- ------ -- ------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Slockton,California Lodi,California Manteca,California Tracy,California <br /> CS 9 REVIGIRLD B-59 3M 3`63 F.P.C13. <br /> is <br />