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FOR OFFICE USE: ------- ------------- ----------------------- ------- ---------------------------------------- ------- APPLICATION -FOR SANITATION PERMIT Permit No. ........................ ---------------- -- --------------------- ----- - (Complete in Duplicate) Date Issued ----------------------------------------- ------------ 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. JOB ADDRESS AND LOCATION..4aA1-z'y-- �'• � -------------------------------- Owner's Name--- -Q .- _ _ L - ----------------------------- Phone------------------------------------- ---------------- . Address----------•-------- -------------- Contractor's Namee -� __ x�� _: rte.--- ---------------- � '" Phone Installation will serve Residence Ir Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 3_ Number of baths _ "" Lot size ____________________ ___ Number of living units: _�_-_ Number of bedrooms . __ __ Numb ----------------------------------- Water Supply. Public system ❑ Community system [I Private E] Depth to Water Table - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,,® Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 41, Previous Application Made: [If yes,date-------- -_.") No.[] New Construction: Yes.[ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Septic Tank: Distance from nearest well__41Ur__------Distance from foundation__/4.----------Material___66�_________________________________________ No. of compartments-.__-______.....__Size_ s °I7l_r_.3_6__Liquid depth______,�7---------------Capacity___J Disposal Field: Distance from nearest well-_o�_C?'.____.-Distance from foundation__/fi�'________-.Distance to nearest of line, f Number of lines---- -01--------------------- -Length of each fine--_?d_-----------------Width of trench"-->> ~------------"--.-- _ Type of filter materia l; __ !! _Depth of filter ma"terial___f F-'..____.__Total en -0 �_____________________ Seepage Pit: Distance to nearest well----------------------Distance-from foundation___________________Distance to nearest lot line__.______________ ❑ Number of pits----------------------Lining material---------- Size: Diameter---------------.-------Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material-_.--_--___._.._____________________-- ❑ Size: Diameter---- ----------- ------- -----------Depth------------------------------------------- --------Liquid Capacity----------------------------gals. F! t Privy: Distance from nearest well------------------------------------------------- from nearest building----------------------------__--_-- -_-_. ❑ Distance to nearest lot line----------------------------------------------------------------------- ---------------------------------------------------------------- Remodelingand/or repairing (describe)----------------------- ------------ ----------------------------•------------------------------- --------------------.-."------------------------------- -----------------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------- 4, M ---------------------------------------------------------------------------------- --------------------- _-_________________________________..____.___________.__-.-.-____________.-..________________-__--_______..________-_____________________ ______..____---- 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and ,reg-V7 of the San Joaquin Local Health District. {Signed]- i-!----- '�.�'1--/L ;- /� '"s'_'s'----------------------------- (Owner and/or Contractor) —r 13y:.: ------ ---------------------------------- �---------------------------- {Title) Plot Ian, showiti size of"lot,location of's stem in relationfo wells, 6uildin s,etc.;can"be"-laced on reverse side 7`�"--- { P 9 Y 9 P 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------------- -- ---------------------------------------- DATE--- l ` -------------------------------- REVIEWEDBY--------------------------------------------------------------------------------------- -------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED_--------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alferationsand/or recommendations------------- ---------------------------------- ----------=-------------------------------------------•------------------------------------------------------- FINAL INSPECTION BY:_ ----------- Date--- .u�- �' ----------------------- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocklon,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8-59 3M 3-'63 F.P.CC.