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1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .c./7. --------------------------------------------------------- - ----------- ----------- ----- p ----- ------------- (Complete in Duplicate) Date Issued . �.1••- � ----------- - - - ------------- This Permit Expires 1 Year From Date Issued Application 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'compliance with County;Ordinance No;. 549. r JOB ADDRESS AND LOC TION....��--J--�- ------------ 0 I / 1217 � Qi _ 5'�` n R - -------------- Address ------------ Phone ------------------------------------ Owner's Name-- -- =�- ---------- --------- ------ ------- --- - - Address---------- } -------------------------=--------------- -------------------------------•-- Contractor's Name----- � -��- ------- ---'-----------------------------------------------•------- ----- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [1] MoFel C1 Other [I Number of living units: ..h__- Number of bedrooms .X.- Number of baths ./... Lot size ---------------- i ` Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table .`eft. W Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe EEY�Hardpan ❑ Previous Application Made {If yes,date--_------._.-.k__-.) No � New Construction: Yes ❑ No ��'FFiA/VA: Yes ❑ No a . W TYPE OF INSTALLATION AND SPECIFICATIONS: 1 j (No septic tank or cesspool permtied if public sewer is available within 200 feet.) ` 4 'I r = ... � ---------------- Septic Tank: Distance from nearest well-- €Distance from foundation ---------_...Mat�r�1. ev, �J Ca acit �®------ No. of compartment}-----r�-------- Size l �� Liquid depth.. p Y / N I' Disposal Field: Distance from nearesf'�weEi-- �'-rsDNstance from foundation..-_.-__..__....._.Distance to nearest lot line...............I k ❑ Number of lines ---------------�-------�.';Lengthyof� each line------------------------------Width of trench -------------------- ----------TyPe of filter material"ry' = `;Depth of;'filter material---------------------- Total length....______....__---------------------L4JSeepage Pit: Distance to nearest well-------------------1.-Distance from foundation........_----------Distance to nearest lot line....-__.-..--Number of pits---------- ------Lining imateriai-z--- --- -----.SizeDiameter Deptn- - Cesspool- D-stance from nearest well-----------------Distance from foundatian--- -_....___......Lining material-......-.-----------------.--___. ❑ Size: Diameter.._....�-----------------------------Depth-------------------- - --------------- Li;quid Capacity :g I .__..Distance from nearest building i Privy: Distance from nearest well - ---------------------- 9 tr ❑ Distance to nearest lot line------ ----------------------- ----------------------------------------------------------------- ------------- ------------------------------ f ` IRemodeling and/orrepaing {describe}:__..... � --------- --------------- ------- ----------------------------- ---------------- --------------------------------------------------------- --- i -----------------------------------:t--------------------------------------------- 1 I --------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ounty 1 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Contractor) (Signed) --------------------------Title � � ' (Plot plan, showing size of lot, location of sys in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY � `AP?LIGATION ACCEPTED BY---- ------------------------------ DATE } BY------------------------- ---- ----------------- ------------------------------------- DATE ---------------------------- REVIEWED e BU I LDI NG PERMIT ISSUED-------------------------------------------------------------------------------------------------- ._ DATE. r 1 , Alterations and/or recommendations--------------------- - ------------------------------------•---------------------------_------------------------------------ ---------------------------------------------•--------------------------------- -----------------------------------------------------------------------•-------•------------•---------•---------------•---------------- -"--- ---- -------------------------------------------------------------------------- -- {� FINAL INSPECTION BY:. Date------- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellan Ave. Q1 w 300 West-Oak Street ` ' t- 124 Sycamore Street 205 West 9th Street t 5locktort,California Lodi,California Manteca,California Tracy,California F.P.CG•