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FOR OFFICE USE: ,� O I U �r I V E�i� �.L 1q3 �j�d � r <br /> Jo-- wG�------------------ n'---- <br /> �-- APPLICATION FOR SANITATION PERMIT Permit No. 941v Tf._. <br /> ------------------------- ----- --------- ---------- -- (Complete in Duplicate) <br /> This Permit Expires 1 Year From Date Issued bate Issued/ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrijitf and install the'work herein described. <br /> This application is made in compliance with County Ordinance No. 549. - [� <br /> - -- <br /> JOB ADDRESS AND LOCATION., --�- � <br /> Owner's NamW <br /> / —' <br /> /-{�---=----- --- ---------••-------•------------------------------ - Phone <br /> Address ' ._.-�_ S Z---------���1.?�1' ' _ <br /> Contractor's Name-- • ----------------------•-------------------------------------- ----------- ------ Phone--------•---•--------.--•-------- - <br /> i <br /> installation will serve: Residence Ef---Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> l Number of living units: ___:'Number of bedroom. Number of bags I---- Lot size ____ x-_/__ _ _-------------------------- <br /> ___ <br /> ;'7 t <br /> Water Supply: Public system ❑ 'ICommunity system El Private ®�pth,to Water Table At. <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay (] Adobe ❑ Hardpan <br /> FPrevious Application Made: (If yes date----------_,.......-) No 2r--'New Construction: Yes �No ❑ FHA/VA: Yes ❑ No <br /> , <br /> ! TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from'nearesf well-- ,Q_- .Distance from foundation-JO-- -----Material------�D <br /> I of com a - -Size-- <br /> No. rtments__ __ ___Li uid de th _____._Ca acitY OD- � <br /> - <br /> .'t � � Q <br /> Disposal Field: Distance fromnearest well..ti�o------Distance from foundation.?_0___.__.___Distance to nearest lot <br /> Number of iine;---------�_ _________-------Length of each line_-__._O-A----------__--Width of trench-----g-''_____.___...__.___. IL <br /> Type of filter material----- .__Depth of filter material__/_$_:.r.____._--._Total length----Zr_o----____________-____ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line._.__._______..._ <br /> ❑ Number of pits----------------------Lining material-__--------------------Size: Diameter-----------------------Depth---------._._____-_-_.__:_______- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation..------------- - Lining material--------------------------____._._._- <br /> El Size: Diameter- ---------- --------------------ibe th---------- I----------------------._Liquid Capacity <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearesf building______.________-______________.___-._._. <br /> ❑ Distance to nearest lot line ------------------------------------------------•------------- ------------------------------------------------------------------------------ <br /> Remodeling and/or repairing (describe)-------------------------'------`--------------------------------------------------------------•-------------------------------------------------------- <br /> ----------------------------------------------------------- ---------------------------- --- ----------------------------------------------•---------------- --------- -------------------------------------------------- <br /> i <br /> :I <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 a �fion Joaquin Local Health District. <br /> (Signed) ._._Owner and/or Contractor <br /> 7 )k <br /> By:----------------_........-­-----------I---•------------------------------------------------------------------------------------(Title)--------------------------------------- -- - --- - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = --------------------------------------------------------------- DATE-----=-�d--/-�f�---------------------- <br /> REVIEWED BY--------------------------------------------- <br /> ------------------------------------------------------------------------------- DATE---•-------------------------------------------------------- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------=------------- DATE--------------------------------------------------------- -- <br /> Alterations and/or recommendations------------------ -- ---------------- ------ -----------------------------------•-----------•----•-----------•------•-------------------•------------------- <br /> I <br /> ------------------------------------------------------------ =---------- ------------------------------------------------------------------- -----------------------------------------------------------.---.--------------- <br /> { <br /> i <br /> I .. <br /> l --------------------------------------------- -•------------ ------------------------------------------------------------------------------------------------------ ---------------------------------------- <br /> FINAL INSPECTION BY:.. ........... -- `` ----------- -------------- Date_ -- �� '--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton Ave. + 300 West Oak Street 124 Sycamore Sfreef ;205-Wes 91h Street <br /> Stoeklon,California Lod;,California Manteca,California Tracy,California <br /> F.P.Cfl. f <br /> 06 F <br />