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1Z <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued <br /> Appli ca4-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work,heoin described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION__ _ 611_ljrl�------- <br /> - -_-_ Q_ <br /> Owner's Name------- .. .... ------------------------- --------------------------------------------- <br /> Address--------.P07-a!------6?------ _�.?—-------------1p%,eI4--------------------------------------------------------------------------------------------- ---_-------------_...... <br /> Contractor's Name----------------------------- <br /> ------------ --------------------------------------------------------------------------------------- -------- <br /> Installation will serve: Residence Apartment House F1 Commercial F1 Trailer Court E] Motel E] Other ❑ <br /> Number of living units: _(___ Number of bedrooms Number of baths Lot size -------------------- <br /> Water Supply: Public system El Community system El private K] Depth to Water Table ft. <br /> Character of soil to a depth-of 3 feet: 'Sand 0 Gravel L] Sandy Loam W Clay Loam El Clay El Adobe I-] Hardpan El <br /> Previous Application Made: Yes E] No [a New Construction: Yes Da No F] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> ' 7e-- �_�--est' W7 ­ . - —_7 � — -- - -j; ,?. <br /> ?- <br /> Septic Tank: Distance from nearest aMe,from fT.ndatio,- _ ! MaferiaI -I5-------- <br /> Y41 <br /> 4 N o. of corripartments-,-7-- Si,e,*-jVX1 ____-___Liquid depth__--- ................Capacity-----Y-00_q-j <br /> Disposal Field: Distance from nearest, Distance from fcundation------a_1-----.Distance to nearest lot line---- <br /> Number o{1ines�_­_­_ __________Length of each lirdo-In-ot" ------------------ <br /> -----------Width of trench--------- __`t'`_ <br /> y - ng -------------Total length----------Z-0-0----------------- <br /> 'pe of filter Ai?&TIZZ------Depth of filter material---- <br /> Seepage Pit: Distance to nearesi well----------------- from Toundation-------------------rDistance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material----------.--------.--.Size: Diameter------------------------Dept k--------------------------------- <br /> Cessl Distance from nearest well-------------- --Distance from foundation------ -------------Lining material_-.---_--_---_------__----_---------. <br /> Size: <br /> aferial-------------- ----------------------- <br /> Size: Diameter------------------- ------------------Depth-----------------------------------------------___iiicluid-Capacity___-= -------:f__—_:gaWs` <br /> D0fa­ntc'e­'from nearest well-------------------------------------------------Distance from nearest building.__---.------____-_--____-__-__.____-.___ <br /> ❑ Distance <br /> uilding----------------------------------------- <br /> Distanceto nearest let line-------------------------------- ------------------------------------------------------------------------------------------------------------ <br /> Remodeling and/or repairing (describe):------------------------- ------------------------------------------------------------------------------------------------------------------------------- <br /> -----­--------------I--------------------------------------------------------------------------------------------------------------------------------------------------­---------------------------------------------------- <br /> ----------------------------------------------------------------- -----------------------------------------------------------------------------------------------------I----------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be don?'in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> __�2 ar7L . . <br /> (Signed)---------------- ---- ---------------------------------------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:---------------------------------------- -------�­---------------------------------------------------------------[Title)----------- --------------------------- <br /> (Plot plan..showing;.size,of lot, location of system in relation to wells, buildings, etc.; can be plaZed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-_ -------------------------------------------------n_�'DATE---- <br /> ------------------------------------------ <br /> REVIEWEDBY------------------------------- ----- -------------------- ----------------- ------------------- ------------------------- DATE----------- ------------------------------------------------ <br /> BUILDING PERMIT ISSUED------------------.----- DATE-----------•-------.-----__ <br /> Alterations <br /> ATE---------­1---------------Alterations and/or recommendations:------- -------------- <br /> ------------------------------------------------------------------------ -------- -------I---------------------------------------------------------------------------------------------------I——- <br /> ------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I....... <br /> -------------------------------------------- --------------I--------------------------------------------------------- ----------------------- ---------------------------------------- -------------------------------- <br /> ----------------------------------------------------------------------- ------ ------------------------­--- - -------------------------------------------- ---------------------------------------------------------------- <br /> FINAL INSPECTION BY:-- - -------- --- -------- ------------- Dafe_._�.r <br /> --------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> S+ock+Gn, California Lodi, California Manteca, California Tracy, California <br /> N, 1i6-9-2M Revised W-2100 <br />