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FCR OFFICE USE: <br /> -„ APPLICATION FOR SANITATION PERMIT Permit No. <br /> ........................ . . ... <br /> .... .................. .. .... (Complete in Duplicate) p - /1 <br /> - .__............ I This Permit Expirer 1 Year From Data Issued Date Issued <br /> ...................................... i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i <br /> This application is made in compliance with County Ordinance 549.q <br /> JOB ADDRESS AND CA ION... 3 3 _.........! 7 ' . .. ................... <br /> Owner's Nama..-....... r ' ... . , .. :. ..._........... Phono..Yl�..r! <br /> --. ��.::: ° . -- <br /> tAddress....l,�.�.3..... O�G,IFL�t'-d.� .. ... <br /> j Contractor's Name..._ .......... <br /> � .. <br /> ' Installation will serve: Residence ❑ Apartment HouseL] C. mmercial ( Trailer ou E] Motel ❑ Other r <br /> j Number of living units: ....... Number of bedroms ........ Number of baths/.Mize ..._.�. ............................ <br /> o <br /> Water Supply: Public system ❑ Community system ❑ .Private Depth to Water TableS�ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel❑ Sa/ndy Loam❑ Clay Loam, ❑] Clay C] Adobe R C]Hardpan <br /> Previous Application Made. (if yes,date.__.__ .......) No —� rvew Construction: Yes 2r i.o ❑ 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 /> Septic Tank: Distance from nearest well./LlO....Distance from foundation..�/� <br /> No. of comoertmants.. Siza..� S. Liquid �/C// ` <br /> I -y`!?---.-----__ �[. x..g...... q ct depth..../ ......_.......Capacity-. ..Q�. i,.. <br /> '. Disposal Field: Distance fiom nearest weIIl/QQ-�.Distacce from foundation_�f ........Distance to nearest lot lina.as.- <br /> Number of lines................y� g' �f r-- r <br /> .... Len hof each line..... .Q_:........y Width of trench ................... <br /> Type of filter meteriel.ns.L.[r(]. ....Dep7h of filter material..,.. . . Total length.....djCQ............._:.:..:_..... <br /> Seepage Pit: Distance to nearest well`Q..Q.........Distence om foundation...!f..A.........Distance to nearest lot line....S.,...... <br /> . <br /> - i G}.•'� Number of pits..../..............Lining material.r�.�...0.ck..Size: Diameter.....,3}.'.�.....Depth.......Z..x:�.:......... W <br /> Ces.pool: Distance from nearest well............ Distance from foundation....................Lining material......... a <br /> 1 ❑ Size: Diameter._...............................Depth.........._........................................Liquid Capacity...........................gals. <br /> .....Distance from nearest buildin � z <br /> Privy{ Distance from nearest well.........._.............._........._.... q...._............_._..-_........_.... , <br /> Distanceto nearest lot line....................................................................................._......_........_.............._..._.........._.. Oji <br /> Remodelingend/or repairing (describe):................................................................................................................................ ........ <br /> ...._................._................................................................................................................................................................................................ ,. <br /> . ._._.. ................ <br /> ._:. .................... <br /> ........ <br /> .................................... <br /> .............. ....._................. ..,. .-----........... .............. .. -..... <br /> f I hereby certify that I have prepared this application and that the work,will be done in accordance with San Joaquin County <br /> r ordinances. State laws, and rules and gula ns of 4he Sen J aqu' Local Health District. '+ <br /> 3 (Signed)..... .. ...........` . .. _._(Owner and/or Contractor) <br /> �`/��-J/,r ( q ... .. ..... <br /> t (Plot plan, showingtsimof lo}, location of sysfem in relation t e , itdings, etc., can be placed on reverse side). <br /> FGfR DEPA TMENT USE ONLY <br /> Y APPLICATION ACCEPTED BY.......... ._ _ ..................................................................... DATE...... 7-/.77!. ................. <br /> ........... <br /> �. REVIEWED BY ..................._............ .. ., ................._..........._.............---------.................. DATE...........--........,1..._----....................... <br /> _.l BUILDING PERMIT ISSUED......_..... ..............................................---._................................ DATE................--............................1-....... <br /> j Alterations and/or recommendations:.................................................___._..._........._.._..._..._..............__.._.._..._...._..--..__._......._.__.... <br /> ................................................_._..._.............__................. <br /> ..... <br /> ... <br /> ......_..._.................. <br /> .--- <br /> ...--- <br /> .............__..............._.......... <br /> ............. <br /> ...... <br /> ................. <br /> .............................................. ... ... ...... ...... ..... <br /> . ....... . .... ..... ....... .. . .. ._.. ... <br /> %i FINAL INSPECTION BY:...._�� � �/( .. Date. f�'. . . ... _.. ....... ....... <br /> i t SK JUIN LOCAL HEALTH DISTRICT <br /> 1{01 !Navlten A... 300 Wet Oak Stet 124 S....o..Suet 205 Wer 91h Street <br /> Herklen,Glllernia Led.. Calilornia Manteca,Calilornla i.aq,Calllornla <br />