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4 FOR OFFICE LI$Et, -
<br /> ---------------------------•---••,........•....... APAL,I> ATION FOR SANITATION PERMIT porrnif No.
<br /> ----•--,.-----------------•,.,,.................,,,,.. (Complete ih Duplicate)
<br /> T Data Issued %'
<br /> P Expires 1 Year l=rom def® issued ��•"� ••• ••
<br /> .......................................................... tiii4 oriel:
<br /> Applicaiidh is hereby made to the Sara Joaquin Local Health District for a permit to construct tend ins-fall the work herein described,
<br /> This epplliicetion i rnado.11n Compliance with County Ordinance No. 549.
<br /> ' off' . ._, � ....r✓
<br /> JOB ADDRESS AN CATI N,..._ c' '....
<br /> Owners hfem9 .G . ............. r-/-.5 r/--tet.- ._._... ...... Phone------------ .................
<br /> Address_............
<br /> ,•.r r_�............ .....---•-••..........................
<br /> —OM1
<br /> Contractor's Name------..... ,...�6_.......... :1:6. .(r_-Z----------- ----------- ...... Phone---...............................
<br /> InsfallaVon will serve: Residence Aparfinenf House ❑ Commercial ® Trailer Court [] Motel ® Other ❑
<br /> Number of living units: ....... Number of bedrooms ?._ Number of baths(-Cot silo ...
<br /> Water Supply: Public system Q Community systom ❑ Private opfh to Wafer Table . ft.
<br /> Character of soil to a depth of 3 fvof: Sand ❑ Gravel ❑ Sandy Loarn q,-C;lay Loam ❑ day-E]- Adobe ❑ Hardpan
<br /> I
<br /> Previous Application Made: (it yes,(late...........,...._...] No © aw Construction: Yes ( IVorQ FHA/VA: Yes ❑ No F4 ,
<br /> TYPE OF INSTALLATION AND SPECIFICATIONS.
<br /> �••-• •--,.-.--.{Neaapfit.tenk or:rvesspgol-permitted_{f--publlc�sevrer:ls-avaiisblsrwlthin��00,4�,of,]:,..A.,_�.;�„�;;;,r.�, �.
<br /> Septic Tpnk: i�rstonce frorn nearest vrell.. ,,,,...Distance ficin foun�lofion.. .w...........M
<br /> ti
<br /> No. of compertmenPs. ................Size.,.,- �'j..jf�.,..:..Liquid depth.--�j_/__---............Crspacity
<br /> .,l..�.���<
<br /> pispOsel F' Id: Distance from nearest well. ` .,41..•...Distance from folmdation. Q 04farice to nearest lot li�a ./
<br /> Number of lines.... ..... ...........Length of each line.( -04,0-_,-.Width of frorich...�: 5
<br /> Ji .,.s-
<br /> Type of filter material__ ._ Depth of fil�or mnteria� .f;?'.�. .��,_,..Total length. .,...,_,_„_-._.._...
<br /> / .... . I
<br /> Seepage Distance to nearest well_..................:..Distance from foundation:_.,..................Distance to nearest lot line.................
<br /> Number of pifs-------I---------------Lining nefenal------------ Sie -Dpmeter............-. Depth........... :...........
<br /> ...._.. ,
<br /> r.
<br /> Co(
<br /> Disfnnce from nearost well............. .Disfonce from foundation,,,,,,,,•,.•,,,.....Lining materiol..........._......................71*
<br /> ❑ Size: DiarnAter....................... -Depth .. ......_-------Liquid Capacity...............,...........
<br /> .gals
<br /> Privy: Distance from nearest well...............:.................................Distance from noar•cist building................,,,,,,•,•,___,.,,
<br /> ❑ Distance to nearest lot line.............
<br /> Reinhdeling and/or repairing +doscribe):........� r�rff�l...,..,c� ��` � � � /.,. .....................................
<br /> ...........--------......,.,v.,...................................................................,... -------•--- ...........,.,.....,.,----------------------••..........................••--
<br /> +.`.!
<br /> ...................................................r..-......................... ----•--...----........,.............----•---•.....,..-_, ........................
<br /> I hereby certify that I have propared this application and that the work will be done In accordance with San Joaquin County
<br /> ordinances, Stp ws, nod rules,( n,& regulvfions of the San Joaquin Local Health District,
<br /> (Signed)............:.- •C .� as✓ - and/or Contract
<br /> B - .1...{Title] 1 �O
<br /> or
<br /> (Plot plan, showing six of of, IOCafiOh o�fVVf system in relalion to wells, buildings, etc., can b® placed on reverse side),
<br /> -FOR DEPARTMENT USE ONLY
<br /> APPLICATION ACCEPTED BY.......... .�c.���_: --�---------_----............., DATE-----
<br /> REVIEWEDBY......................... ............................................................ DATE
<br /> BUILDINGPERMIT ISSUED.--...---•---••----•.........................................._..................,,,,,,.........•---- DATE...................._...._.._...........--•,..
<br /> Alterations and/or recommendafions;..................•... .-. ..............,...,........I.................. ................,,...........................
<br /> . .......,....._..._._.............
<br /> ......................................................................................•.............................................................................. ---............. ...,.................
<br /> ..,.,...--•--•........
<br /> FILVAL INSPECTION' BY:_!�"'`�'..' � .2 --------- �.�..._
<br /> Oate_-- r
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> Huzollon MO. 30o Wos1 Ook Straot 124 Syeamora Simi 205 West 91h Street
<br /> Slockslon, Callfornlo Lodi,Callfa,nln hlantocm.
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