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�FOR OFFICT,USE. <br /> -- ----- ---------------------------------------- <br /> ............... --------------- --------------------- APPLICATION FOR SANITATION PERMIT -Permit No. <br /> --------------------------------------------------------- (Complete in Duplicate) Date Issued <br /> --------------------------------------- This Permit Expires I 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 complianlceylth County Ordinance No: 549. <br /> JOB <br /> V <br /> , ADDRESS AND LOCATION:__5jjPT:__ L 1- ..... ------------------------------------ <br /> Owner's Name-------•----------- ---------- -------------------------------------------- ------------------------- -------------- Phone------------------------------ <br /> Address..................1_� <br /> T - --------- ------------------------------------------------------ <br /> '2- -----Q.0 .........57-------- Al , -f= <br /> ----------- ------------- ---9 <br /> ------------- <br /> Contractor's Name-----6_141AI F_FZ�. ---------------------------------------------------- ------------------------------•------------------- -- Phone <br /> --------------------------------- <br /> Installation will serve: Residence D Apartment House El Commercial [-] Trailer Court E] Mofel 0 Other. E] <br /> -7 --------------------------- <br /> Number of living units: -1---- Number of bedrooms -7777Number of baths --- Lot size <br /> Water Supply.: Public system E-] Community system E] Private UDepth to Water Table/ t. <br /> Character of soil to a depth of 3 feet: Sande_Gravel E] Sandy Loam E] Clay'Loam E] Clay Ej Adobe E]" Hardpan 0 <br /> Previous Application Made: (If yes,date....................1-No �'New Construction: Yes ❑ No E—PHA/VA: Yes E] No E]-- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> -(No septic fank.or,cesspool permitted.if,.public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-- ------ ---Distance from foundation--------------- ----Material----------------------------------------- <br /> a-N(DSTI W6— No. of compartments--------------------- ----Size--------------------------------Liquid depth---------- ------------•--Capacity---------------- <br /> ✓Disposal Fiefcl: Distance from nearest well--- Distance from foundation -------Distance to nearest lot line___- <br /> it�z NnG_T1-W6Number of lines-----------/---------------------Length of each line_____._ ------------- Width of trench ------- <br /> 1)Pr- Type of flifer.materiai---,Rt)C--K..--Depfh of filter material_____ Total length---:-------------I -- -------------- <br /> Seepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest lot line----- ----------- <br /> F] -Number of pits----------------------Lining material---------- ............Size: Diameter-----------------------Depth-------------------------------- , <br /> Cesspool: <br /> epth_-------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____-.-._.___-____-_-.____-____.--_ h <br /> ❑ Size: <br /> aterial-------- -------------------------- <br /> Size: Diameter---------r-----------------------------Depth----------------------------------------------------Liquid.Capacity-.--------------------------gals. <br /> Privy: Distance from nearest well--------------------------------------------- ---D�stance from nearest bu�l&ng ---- - --------------- <br /> - -__Distance❑ <br /> tonearest lot line-------------------------------------------------------------------------------------------------"--------- ------------------ <br /> Remodeling and/or repairing .(describe):______.____- .-._._.- ------------------------------------------------------------I--------------------------- ---------------------------- <br /> ---------------­-1------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ <br /> ---------------------------I------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------- <br /> ------------------------------- -------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------� <br /> Z <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> e <br /> .ordinances, S�fjq+e laws, and rules and regulalions. of the San Joaquin Local Health District. <br /> (Signed)--- -- ----- - <br /> ------ ---- ---------- ------------- ----------------------------------------------- ------------(Owner and/or Contractor) <br /> By:---------------------------------------------------------------- ----------------------------------------------------------------------I[Titlej-------------------------------- <br /> (Plot plan, showing size of lot,'Io 1 n­of'_iys+ern in relation to wells, buildings,-etc-.; can 6e.placed on reverse side)., <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----.... ---- --- ------------- -- -------------- ------------------------- DATE------�'f' -' « - - <br /> REVIEWED <br /> ATE------- <br /> REVIEWEDBY------------------------ ------------------ --------- ----------- ----------------- ---------------- ----------------------- DATE----------------------------------------------------------- <br /> BUILDING PERMIT ISSUED________________.____-_- <br /> - -------------- DATE----------------------- ---- --------------- ------------- <br /> Alterations-and or recommendations:____.-._________________ _ ----------------------------- <br /> ---------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------- ------ ------------- ------------------------------------------------------------------------------------------------------------------- ----------------------------- <br /> ------------------------------ --------- ---- ---------- ------------------ .........-------- -------------------------- -------------------------------------------------------- -- ------------------ <br /> - ---- <br /> ------------------- ------------------------------------ ------------------------------------ - -------- -- ------------------------ -------- - <br /> -------- <br /> FINAL INS <br /> PEC-ION - A-- - -- ... ... 6 _ Date--.... -- -- --- ---j---/4-,- <br /> ---------- <br /> - ------ --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1-601-E.'Mazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Z 'Stoclr''n CaBforma Lodi,California Manteca,California Tracy,California <br /> %4.P.Cb. <br />