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FOR OFFICE USE: -� ---------------------------------------------------------- 1 ___..____..________________ ------- APPLICATION FOR SANITATION PERMIT Permit No. .2 .9`.. = ___-._ Complete.in Duplicate) "_ This Permit Expires I Year From Date Issued Date Issued Applicaflon is hereby made to'-,the San Joaquin.Local Health District for a Permit to construct and install the work herein described.' This application is made"in compliant, with County Ordinance No. 549- f �- �r�Z `$�pT 03 T 1 Y. JOB ADDRESS A L CATION Owner's'Name----- --------- ' - - Address__' - / s t Contractors Name - -------- Phone Installation will serve: ;Residence Aparfinent ouse ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ l I Number of living units: __ __ Nu bar of bedrooms __ Number aths - Lot size __ y / r w F- a� F Water Supply: Public,system_'❑.. Community system ❑ . Private Depths `Water'Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.[FClayLoam ❑ Clay E] Adobe ❑ Hardpan ❑ Previous Application Made: (lf yes,date---------------------) 'No ❑ New Construction: Yes ❑ No ❑ PHA/VA: Yes ❑ No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: (No,�septic tank`or cesspool permitted if-public sewer is available within=200 feet.) - t SA 1 r Septic ank: Distance from nearest well----_-----------Distance from foundation + compartments foundation__.__1 er � —------------------------ N' _______________________ No of .__--��__ :Siz_ X_Y_ -L'quid depth-------�-------- CaPacity_.1 !9_ Dispo Field: Distance from nearest wefi_�d'._...__stance from foundation____J_V-__._____Distance to nearest lot IineS_:____.____'�� i „h _ _ ( �-r--- length -� �Number of lines________ __ - - - -----------Length of each Q---r------------ Width of trench-----� --f------------------ .Typrial____„__ p.._. Depth of filter maferial---------- length-------c�� ---------------------e of filter mate Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------_-----.Distance to nearest lot line----___.------- .. ` ❑ I Number of pits----------------------Lining material--------_-------___---Size: Diameter--------------.--------Depth----- _•------------, ` Cessp ol: Distance from nearest well-----------------Distance.from-foundation___ ----------------Lining material_---------------------_-_________-- ❑t Size: Diarrieter= - --'Depth----��-------------.- - Lfquid CapacltY� gals. � -. -- - T r Privy:' .F Distance from nearest weli____ _._______-__ Distance from nearest building _____________ _ ___________ --•---- ❑�ji Distance to nearest lot line ----- ---- -------------------------------------•------- Remodelingand/or repairing (describe)=--------------------------•-------------------------_ -----------------------------•---------•-------------------•-•---------------------------------- I ! f-• -------•-------•--------------- --- i ---------•---='------------------------------------------------------------------------------ ---------- --------------- ------------------'--------------------------------------------------•--------------------------------------------------•------------------------------------------ -------------------------------•---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,!State la and rules and regulations of the San Joaquin Local Health District. ------------------ •-----------------•-------- � and/or Contractor)(Si ned)----- --------- -------------- ------- ------(Title) ----- (Plot plan, showing size�of lot location of system to relation t wells, buildings, etc., can be placed on reverse side). 1 $ t FOR DEPARTMENT USE ONLY APPLICATION:ACCFPTED�BY'` --------.------------------------------------------ DATE------ REVIEWED ----REVIEWED BY------- t- --------- = '---------------------------------, ,`�r. _ DATE - -------------------------------------------------------- 11 BUILDING PERMIT ISSUED `_ ----------------------------------------------------- DATE--------------------------- -- ---------------------- Aiterations'and/or recommendations:._.___:..___._. ----------- ' ! 1 r !, , i r € ---------•--------------------------------------•---------•---•- _ - t � ___ .___ ._.------_---_.y__._.____T r________,__-________.___ -------- _ __ _ _ _._.__.______ FINAL WSPECTION 13Y:. ---- ------ Date----------- -----------_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E..Haiellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocklon,California Lodi,California Manteca,CallforniaT- V Tracy' - ,California ES 9 REVISED 0-59 3M 3-'63 F.F.0I7.