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FOR OFFICE USE: 3_< _ APPLICATION FOR SANITATION PERMIT PermitO. ....................... ------------ (Complete in Duplicate) I Date Issued This Permit Expires 1 Year From Date Issued ------------------------------ -- - Application is hereby made to the San Joaquin Local Health District or a permit to construct and install the work herein de ribed. This application is made in compliance with Cogr>_ty Ordinance a3. 49. i a--:-------. i JOB ADDRESS AND CATION___�-�_ .-_.--r�-- -t� _1.� � -1 el-_.---' .-- - ---- -- Owner's Name------- k ✓I =-------- lt_V1-:`� ---- = -/- ----j-- Phone Address —'� -----------��-��_[��/ -------J � _-------- Contractor's Name--------- - �- --------,}=--c'-�--�-`�--------------------------- ----- Phone-------------------r--------------- I Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court-['] Motel ❑ Other ❑ Number of living units: _4__ Nu er of bedrooms .__'?--_Jumber of baths ----/_ Lot size -------_________._____._______-__-________--______________ 1 Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl '6)-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ San _Loam ❑ •Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (if yes,date____________________) No E New Construction: Yes r to ❑ FHA/VA: Yes [� I�o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 I• (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p+ Septic Tank: Distance from nearest well-----------------Distance from foundation---------------------Material_.C4_,m o- e--_______._..__-.._____- No. of compartments--------------------------Size---------------------------___Liquid depth------- Capacity----------------------- Disposal Field:? Distance from neare t well-----------------Distance from foundation___ C-j___._..Distance to nearest lot line__ __-____. ®� Number of lines_-_____ _____ _ Length of each lme___-__ �� g 40-�_-=_.._ Width of trench-----r - -. ------------------- Type of filter material- lt— �~G---_Depth of filter material-- _� .....#otal length__________ ______________________ ) -------- Seepage Distance to nearest well____'---------Distance oma�,f�ound __ ation__ __________Distarce to nearest lot line;_.__ _ - Number of pits____ -----------------Lining material_ i;�___.-__.Size: Cesspool: Distance from nearest well-------------____Distance from foundation--------------------Lining material-.-.____...._..____._____.___.._._ ❑ Size: Diameter------------------------------------ Depth----------------------------- ---------------------Liquid Capacity-- -------------------------gals. Privy: Distance from nearest well ___________________________---------------------Distance from nearest building------------------------------------_._._. ❑ Distance to nearest lot line----------- ----- ----------------------------------------- Remodelh g and/or repairing (describe):.-____-.--- �' _ � __ Q__,-,1191_11a.-7_-'%-"C ---------------------- ----------------------------_____ 40 --------------------`------ --------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rulesand regulations of the San Joaquin Local Health District. (Signed)--------- ------ ---------- ------------- -(Owner an /or Contractor) . -/ By:.-. ---- (Title) '- (Plot plan, s owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -41' -- --------------------------- ------ --------------------------------------.- DATE-----y= '"-a--------------------------- REVIEWEDBY--------------------------------------------- ---- --------------------------------------------- ----------------------------- DATE---- - ----------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------- ------------ -------------------------------------------------------------- DATE----------- ------------------ ----------------------------- Alterations and/or recommendations:--- r------------------------------------------------------ ------- •-------------------- ----------- ------------------------- - ?' -. c 1 t-------------------r-------- ------------------------------------------ 4j! r -- ----------------------------------- ------------------------------------------------------------- -------------------------------------------------- ---------------------- ------------- ---- ------------- FINAL INSPECTION BY:------. Cr-7,--------------------------- ------------- Date----- ----- ------------------------------------ ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street • ry. Stocklon,California Lodi,California Manteca,California' Tracy,California