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APPLICATION FOR SANITATION PERMIT Permit No. .,1. _ .3 <br /> (Complete in Duplicate). al f <br /> This Permit Expires 7 Year From Date Issued <br /> =i T, 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 County Ordinance No. 549. <br /> JOB ADDRESS AND OCATION--:------J --, - -------C /_----------- <br /> Owner's Name r. d •--- _-------_-- ---------------------- ----------------------------------- Phone <br /> Address__/• 3--_ ,{} j <br /> Contractor's Name t ---- - -------- ----------------•------------------ -- --- Phone----------------------------------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ railer Court ❑ Motel ❑. Other ❑ <br /> Number of living units: _ __ Number of bedroorn"s __/__ Number of bat Lot size'-___!_5___ __- a_______________ <br /> Water Supply: Public system W._�Community system E2/Private ❑ Depth to Water Table s ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ ',:Sand Loam ❑ E dao Loam Clay Adobe and an <br /> Y Y ❑ Y ❑ � P ❑ , <br /> Previous Application Made: Yes E❑ No [E-"N"ew Construction: Yes ❑ No Pj-' FHA/V-A: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool pi rmitted ifublic sewer is available within 200 feet.) a <br /> Septic Tank: Distance from nearest well -F°�_-Distance from.foundation__f_Q_ Material_-,( //fl�yPJ12.e f� <br /> --- <br /> Disposal field: Nc of compartments —____�-____.__�Size__- _lP_ _, _b:.__liquid dep;h_- ..t,...: =__Capacity-__ �_d <br /> No <br /> tante from nearest weI(__/ I _Distance from foundation__2_�_._____-Distance to nearest lot line__________ <br /> Number of.lines_'____-�__ -_-�� f� Length of each line-_-_ �--_-____�- Width of trench----�_y_ _______________ <br /> Type of filter material__-c:_ _ Ot%>�..Depth of filter material-W./'k----_-_ Total,length_____9O__ ________________________' <br /> - <br /> Seepage Pit: Distance to nearest well________________ `°-__Distance from foundation--------------------Distance'to nearest lot line_______._______:. <br /> ❑ Number of pits_-I_----------------- <br /> f eLining material..------.-_---,;, Size: Diameter-----------_---_---Dep <br /> t <br /> h--------------------------------- <br /> Cesspoo • Distance from narest well______________�.Distance fromZfoundaton_ ----- --.-- -_. ingmaterial El Size: Diameter. -----_----- ----------------=-Depth ----- - -- -_ � u.d CaPactYr-d 'gals. 5- <br /> i <br /> k Privy: Distance from nearest well________________________________ ___________Distance from nearest building_____._-_____________________--_-- _--.-- <br /> Distance to nearest lot line .--------------------� -------------------------- ------------ ------------- <br /> f <br /> in and/or repairing <br /> rn <br /> , <br /> ; <br /> ___________________ -_-_-__ .___ ____-------_____--______-___________ _ ___-­------------------ _ ______ __ ______----_ __-_ _______-__ _ _________.___.__- - .. - <br /> �; <br /> = -------------- -- <br /> - - - ------------------------------- <br /> I hereby certify that I have prepared•this ap-plication and that�tlti work will be done in accordance with San Joaquin County <br /> ordinances,' a laws, and rules and r guiations a Sa �J,oiaquin Lo I,Health District. <br /> { <br /> (Signed)---- -- -(, --- F I. ----- ......caner and/or Contracfarl. <br /> r <br /> BY=--------------------------='---=---------- ----_--- —------------ '�---------------------- ------------------------------- (Title)-- ___V/ -------------------._....- ---- <br /> (Plot plan, showing size of Iot; location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTME T USE ONLY <br /> APPLICATION ACCEPTED BY__________ __ ___________ -- — <br /> DATE------ f <br /> REVIEWED:.BY--------------------------- -----:--- ------- - ------------------ ----- - ----------- -------------------- ---- DATE_- ' <br /> BUILDING-PERMIT ISSUED------ -'----------------------------------------- --------`-=-------------------------------- DATE----- -----------------=------------------- -------------- <br /> Alterations and/or recommendations; --------- ------------------------------------------------------= ------------------ ---------------------------•---- ------ <br /> ------------------ ? <br /> F . <br /> - <br /> -- - -�-L <br /> a <br /> 1 <br /> - ----------------------------- ------------. <br /> INSPECTION .BY - --------------- ------ Date------- <br /> SAN <br /> - ---_SAN <br /> f� <br /> JOAQ+UIN LOCAL HEALTHDISTRICT F <br /> 130 South rtmoricanl Street 300 West Oak Street -132 'Sy.—.niere Street 814 North "C" Street <br /> St..kA California' .,., Lodi, California Manteca. California Tracy, California <br /> ES-9-2M .Revised 8-'59 F.P.Co. _ ' <br />