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r j APPLICATION FOR SANITATION PERMIT" Parmit No. __ y ` 0 1 (Complete in Duplicate) f 7: 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 LOCKnON__1----.- f -------------- -- -------------------------------------------- Owner's Name---------4 ----- -------- - Phone-- Address_.---•------ - - --.:.----� -------•------------•-----------------•-------•- --•---------------- ' Contractor's N . � -- ---•--------=------ �:_ - - Phone ----------- -------------- Installation will serve: Residence ❑ Apartment House ❑ CommercialTrailer Court E] Motel ElOther ❑ t Number of living units: _Q-_ Number of bedrooms - Number of baths - __ Lot size ___s --------------Water Supply: Public system CommunitY system ❑ Private ❑ Depth to Water Table��ft, ! Character of soll to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado b ardpan ❑ Previous Application Made: Yes ❑ IN0 New Construction: Yes ❑ No�� TYPE OF INSTALLATION AND SPECIFICATIONS: `` �� (No septic tank o'r cesspool permitted if public sewer is available within 200 feet.) y - ,,. � I Septic Tank: Distance from nearest well-----------------Distance from foundation__.-____.----------- •`��{� �``yn' fir- No. of com artments_..___ -- - -- Material------------ M �E �1/�3 p --- Size_-. 1 p -----------------Liquid depth------------------------ -Capacity-----,, �4 Disposal Fiel Distance from nearest well_--_--------_-_-Distance from foundation----------_---------Distance to nearest lot line 34 -�7 ❑ Number of lines-----------------------------------Length of each line--------- ---_ Type of filter material--------- Width of trench---- ---_::---------- Depth of filter material ---------- -----Total length--------------------------------------------- Seepage { }t Pit: Distance to nearest well_ / W b{ f '--____Dista e fr _oan tion_____-----.Distance to nearest lot iine__... 1 s Number of pits___.___`_____- __Lining mater' 1 ze: Diameter - -- ------Depth--- ----•--------------- l Cesspool: Distance from nearest well,_________.__-_Dista undat;on in _ ❑ Size: DiameterR-- - -------- -- -- - -- --Depth-- --- ---- --- .Lin material Liquid Ca ach, Privy: Distance from nearest well y �`"°°'�' "'""` q p, ,Y � gals: - --------------------------------- from nearest building----------------- ❑ Distance to nearest lot line__--- _ -------------------- ------------- Remodeling and/or repairing (describe):- ___-__ __ - k --_-- ------=------------- • • ; --------------- ----------------------- --•---------- - c--:- n �? -� ' r-� • y � -------------------------- *1 _ n . t ----. - -- ---by - ti -- - - - --- •-------------------------------------------------------- e work will be done in accordance with San Joaquin County- ordinances, Stat a1 s, an ul and regula ions of the San Joaquin Local Health District. (Signed)_•----_----. 1 �p _____________ _{Owner and/or Contractor ' BY�--------- ----- -------------------------------------- --------------------- -------------- {Title)- ----- r":r� {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pla ed on reverse side i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY�--------_ - DATE. REVIEWED BY----- ----------'- -------- -'� --- --- -- ------- - -------- -------- ---- ----- ---------------------------------- DATE- --- ----- --•----- -- �-------------- ------- --- -- DATE__ -BUILDING PERMIT 155i1ED. ---• ~ DATE------- Alterations and/or recommendations: --------------- = = I ,; - t ---------------I--------------------- ----------------------------------------------------------------- - ---- -•--...------- l� ' .---- ---- =--------- -- - -----------------------------------------------•------------- ----- -- ------------------------------- r - - --- - •--- - - --------------------- INSPECTION BY: -� -------------- Date--.------- -- __ FINAL SAN JOAQUIN LOCAL HEALTH DISTRICT f30.South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Sfockfon, California Lodi,,California Manteca, California Tracy, California i f 5-9-2M 10-52 Revised W-2100 j _ f