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/ FOR OFFICE USE: <br /> --{P­ r ­�---------------------------------- - q <br /> ______ _________________.._..--._-.-.._ ____..__. APPLICATION FOR SANITATION PERMIT Permit No.c.�.�_y/. -4 <br /> -- -------- --------------------------- ---- (Complete in Duplicate) <br /> Date Issued <br /> ------------ This Permit Expires 1 Year From Date Issued <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 Count ina ce No. 549. <br /> 1/30y �0-�i <br /> _ <br /> JOB ADDRESS AND LOCATION -a� - - Gf= --------------------------- -----�� -- 7------ �r <br /> Owner's Name--------- <br /> � / r�---c`C� �" ��_ <br /> -- ----------------- ------------------------ Phone <br /> Address-------------- ---- r- <br /> Z--------------------------•------------------------------------ <br /> Contractor's Namer "� f— --------------- ` "' ' Phone-------------- •----••--•---------- <br /> Installation will serve: Residence [] Apartment House ❑ ommercial Trailer Gourt ❑ lotel ❑ Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths _Z Lot size <br /> Water Supply: Public system ❑ Community system ❑ Private/ff Depth to Water Table o__ ft. r <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date....................) NoR\ New Construction: Yesg No ❑ FHA/VA: Yes ❑ No ❑ " <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> p frofoundation____fd_I___..Material_`�� <br /> Seo Tank: No} of compartmentst well---�.----------Distance,e <br /> Disposal Field: Distance from nearest well.._.____-.._..-Distance from foundation--------------------Distance to nearest lot line----------------- <br /> El <br /> Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- <br /> Type of filter material-_-_-___.......... .....Depth of filter material--------.--------------Total length------------------------------------------ <br /> Seepage <br /> __.-_--..._----__--- _--_----_---__Seepage Pit: Distance to nearest well______________________Distance from foundation--------------------Distance to nearest lot line__._---.----_-.-_ <br /> CNI <br /> Size: Diameter-----------------•----Depth-- ------------------------ .k <br /> El Number of pits----------------------Lining material----------.-----_--.-- _---- <br /> ZA <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-_- ..........Lining material--- ------------------------------- <br /> Zy <br /> ❑ Size: Diameter----- ---- ------Depth------------------------------------ <br /> - -------------Liquid Capacity- --------------- - ----gals. <br /> Privy: Distance from nearest well----------------.---------. --------_-Distance from nearest buildingt <br /> ❑ Distance to nearest lot line------------------------- -------------------------------------------------------------------------------------------------- - J <br /> Remod ling and/or repairing (describe�:_r - <br /> --- -------------------------- <br /> ------------------ <br /> - <br /> ----------------------- <br /> --- ------------------------------------------- -- - _-___ _-::_--- <br /> ---- ----------- ------_ <br /> ------------------------------- -- -------------- -'------- -''------_ =--`-'------ --------------=------------------------- <br /> I <br /> -------------`-"-'•-'t <br /> I hereby cerci y fhat 1 have prepare this application and that the work will be done in accordance wi San oaquin County <br /> ordinances, State Paws, and rules and regulations of the San Joa uin Local Health District. <br /> `7 i� �d L ir <br /> �r ( )--�_ �.t— llZ - i Tp (Owner <br /> ( <br /> (Signed)-�------ ------------- ----------------- �• �- -- a# <br /> BY=------------- --------------------•-------------------------------------------------------------------------------------(Title)t--6_ S. <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a <br /> FOR DEPARTMENT USE ONLY + <br /> APPLICATION ACCEPTED BY_._._._. ._._____. <br /> DATE <br /> REVIEWEDBY ----------- ------------------ -------- -------------------------------------------- DATE--.-.-._---------------- <br /> BUILDING PERMIT ISSUED----------------- --------------- DATE--. ------------------`------------------------- -- ------ <br /> Alterations and/or recommenda#ions._--- �- <br /> ---------Z"^ <:4-, s--- ---- ---- -- ----- ------ -•- ---`--- -----------`�-- f---G---6: ' ------------- <br /> ------------------ -------------- ------------- ------------ <br /> FINALINSPECTION BY------------------ - -------------- --- ------•--- ------------ Date--------------------- ---- ---- -------------------------------------- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1401 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street <br /> Slocklon,California Lodi,California Manteca,California Tracy,California <br />