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FOR OFFICE USE: ----------------------------- ---- 4 a.5 APPLICATION FOR SANITATION PERMIT Permit No. -._-------------- (Complete in Duplicate)-- - - - - Date Issued -- / � �- _ _____ -------------_--_---. r 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. - i JOB ADDRESS AND LOCATION__24 -- - -- �j _ .. - Owner's Name------ --------------- ------------------------------------------ Phone---------------------------------- Address-----•-- .l----- x-?-------- ---- -------------------------------- --- ---------------------------------------------------------------------------Contractor s Name.---.-=-# ----- .-�---•- - ----/�------------------------------------ ------------------------------ , Installation will serve: Residence Apartmerst House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: __f____ Number of bedrooms _J�t_ Number of baths E----- Lot size _J_ - !_sd?_•]+ -O{�!t__ -----•----- Water Supply: Public system ElCommunity system ❑ Private { } Depth to Water Table _ ft. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe_jF Hardpan ❑ I Previous Application Made: (if yes,date________ ___________) No f] New Construction: Yes A No ❑ FHA/VA: Yes ❑ No ❑ TYPE,OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.] _' ----------- Q Septic Tank: Distance from nearest well---SV--------Distance from foundation.-____�___-______.Materialt f Capacity 17-7 -------- Ni No. of compartments---A`------- ----- Size �� --------Liquid depth-----�------------ -- P y.. eb---------.Distance to nearest lot line--------Disposal Field: Distance from nearest well.��______Distance from'.foundation----__.._ Len th of each line-___ �-- - -____---Width of trench.--- 'y�_---____-___------------ .T Number of lines---- ------ --------------- g De th of filter material __�_ __'�_____-_.___.Total length--_L1.47�______-•------------------- Type of filter materialA_fi p from foundation__!a'_____.___.Distance to nearest lot line__��___--___.- Seepage Pit: Distance to nearest well---/__Q7P'_- !_-Distance Div Number of pits----- material_ ______--. Size: Diameter------Y-Y---_------Depth__Ar------------- Cesspool: . Distance from nearest well------------------Distance from foundation---...............- Lining material------------------------------ al-- s. ❑ Size: Diameter------------------------------------- Depth--------------------- ------- - -------------------Liquid Capacity----------------------- ---g Privy: _ Distance from nearest.well--------------------------------- ---------------Distance from nearest building---------------------------------------- Distance to nearest lot line - --------------------- -------- ` i _ _ ________________________________________ Remodeling and/or repairing (describe):_______.;--------------- ---------- _____________________ ________________ I ----- -------------------------------------- t - ---------------------------------------------------•------------•----•--------------------------------------------------------------- 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 anArgulafions the San Joaquin Local Health District. (Owner and/or Contractor) (Signed) -(Title)------- -------------------- -------------- ------------ (Plotplan;showing size of lot, location f system in relation to wells, buildings,'etc:; .can be placed on reverse.side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... ,ra!�a 't- DATE----44_d7-O----------------------------------- REVIEWED BY------------------------- ------------ ------------------------- ---------. -------------- ------------------- ------ DATE----------------------•----------------------------------.. BUILDI.NG PERMIT ISSUED-------------------------------------- ----------------------- DATE------------------------------------------------- ---------- Alterations and/or recommendations:__ -____________-_.__ n -•-------------•------- ---------------------------------------------------------- --- . - - -------------•------------=--------------------------------- ------------------ ------------------ ------- -------------------------- �� FINAL INSPECTION BY:_ _. ��a ------- Date--- - - SAN JOAQUIN LOCAL HEALTH DISTRICT ^ �� 1601 E.Hazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Lodi,California Manteca,California Tracy,California 5tocktan,California i ES '4- 9 REVISED B-59 3M 3-'63 F.P.CG. �L ��