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w, <br /> APPLICATION FOR SANITATION PERMIT Permit No. --- ----- <br /> (Complete-in'Diuolicafe)'� <br /> Date Issued, <br /> Applica4ion is hereby made to the San Joaquin Lotal 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 /> 01 <br /> JOB ADDRESS AND LO ATION] - <br /> -------- :>__P�17----- oklz---- <br /> ��l -------------- <br /> ---- -- ---- --- ------ -------------------- ----- -- __2 <br /> 1 — _e . -- - ----P-h--------------------------- <br /> Owner's Name---__-___--_ --------- ------------- ---------- one----- <br /> ------------------ <br /> ...... ..... <br /> Address--------- ----------- <br /> - -------------------------------------------- ---- -------------------------------------------- Phone----------------------------------- <br /> Contractor's Name----------------- <br /> Installation will serve: Residence ;—�parfmenf House [-] Commercial E] Trailer Court El Motel L] Other Ej <br /> Number of-living units, Numb f bedrooms ./-. Number of baths _/___ Lot size ----------- <br /> Water Supply. Public'sysfem 2­- Ommuor­nify sysfem-[:j -Pi­ivatW_0 _D_el31h-f6-Wafer Table -------- ff. <br /> Character of soil to a depth of 3 feet: Sand Ej Gravel E] Sandy Loam E] Clay Loam E] Clay (:] Adobe fl_lq�,Qp_ <br /> an 0 <br /> Previous Application Made: Yes ❑ No ew Construction: Yes e-:- to El i <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: f <br /> (No septic tank or cesspool permiffed if pub is sewer,is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_, <br /> ,11- ,e_Di,tarce from ioundafion/4 ------Material---- <br /> No. of compartments-------- <br /> ------------------ ---------- <br /> ----------Capacity--- -- ------ - <br /> Disposal Field: Distance from nearest well.4_ft_0_rW_<4;I5isfance from foundation__/__i0 Dista6ce to nearest lot line___-_- <br /> Number of lines W <br /> Lff�7�Viclfh of french <br /> Length of each I;n <br /> Type of filter material_ -_)�_K__.Depth of filter material---_I/V- -------Total length------------ ------------- -------- <br /> Seepage Pit: Distance to nearest well------ -------Distance from foundation__------ -------aisfance to nearest lot line----------------- <br /> El Number of pifs---1-------------------lining material-_---------------------Size: Diameter- -------------- ----Depth------ ----------------------- <br /> Cesspo& Disifance from nearest we.II___41------------Distance from foundation------------------- Lining material--______-_____-_----._ <br /> ❑ <br /> aterial-----------------------El Size: Diameter-- i-------------#-----------------.Depth------------------------------------- --------------Liquid Capacify-.--------------------------gals. <br /> Privy: <br /> Distance from nearest weIT7,�'------------------------------------------Distance from nearest building------ ----------------------------------- <br /> F1 Distance to nearest lot line--------.: <br /> ) � 1 <br /> Remodeling <br /> ine--------Remodeling and/or repairing (d05cribe):----------------------------------------- ------------------------------------------------------ <br /> -----------------------------------------------------------1--------------------------------------- --------------------------------------------------------------------------------------------------------------------- <br /> 4 <br /> --------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------ ------------------------I---------------------------------­------------------------------------------------------------------------------------------------------------ ------------- <br /> I hereby cerfify.fhaf I have prepared thi application and that the work will be done in accordance with San Joaquin County <br /> ordinanct e laws, and rul a d regula, of the San Joaquin Local Health District. <br /> A <br /> {Signed) 151.I-Ai—n-4-------- - -- ------------------------------------------ ---------------------- <br /> By:----------------------------------- ------------------------(Owner and/or Contractor) <br /> -------- -- ------- ------------------------------- ------------- ---------------------------(Title)--------------------------------------------- ------------------ <br /> (Plat plan, showing size of lot, locatio of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------_-.--- ---- C", <br /> ------------- ---- ---------------------------------------------------------------- DATE-------7— <br /> REVIEWEDBY------------------------------------ ---- ------------------------------------- ----------------------------------------- DATE <br /> BUILDING PERMIT ISSUED-------------------------------- I-------------------------------------------------- ---------------- DATE.-- -------------- <br /> Alterations and/or recommendations:_______.___--____.-i <br /> ---- 4� <br /> ------------I..............­----------------------------------------------------I-------------------------------- <br /> ------------------- <br /> ---------------------------------------------------I-------------------------------------=--------:-------------- ------------------------------------------------------------ ----------------------- <br /> Af ---------------- <br /> -------------------------------­­-----------------------------i---------------- -- <br /> --------------------- ----------------I---------------------------I---------------------------------- <br /> _ ----------------------------------------- <br /> --------------------------------------------- <br /> --------------------------- -------------- ---------- ---------------------------- --- -------------------------------------------------------------------------------------- <br /> -------------------------------------- -------------------------------I----------------------- ---------------------------------------------------­­­-------------- ----------------- --------------------------------- <br /> FINAL INSPECTION BY:.-----V. KYA-141101------------------------ ---- Date...... ...... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Sfock+on, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />