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FOR OFFICE USE: ------ Permit No. .....to (�- _ ---- APPLICATION FOR SANITATION PERMIT ------------ --------------- ------- ----------------- =- (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. 49. JOB ADDRESS AND LOCATION---� �� = '= _ - '= --------- -------------------------------- -------------- Owner's Name ---.-. Phone... "" ------------------ -- Address-..-------- ` .5 . . --- - ----+ - --- -- Contractor's Name--- 1 --- Phone Installation will serve: Residence M__x-partment House ❑ Commercial ❑ Trailer Court El Motel 0 Other Number of living units: ...... Number of bedrooms _ -- Number_of baths..l..-_ Lot size ..- r -llts7`f-_ Water Supply: Public system A ---•--------•-----------•-- �--ommuriity -system E]:-Private ❑ "Depth to Water Table . - ft. Character of soil to a depth of 3 feet: 1 Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ki--l4ardpan ❑ Previous Application Made: (If yes,date--------: _,_-__.._} No New Construction: Yes [B"�No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i - Septic Tank: Distance from nearest well----- "`..-.Distance from foundation�Q...............Mate rial....._.__.....-.-_ ,."....... p ...�._ LL r No. of compartments-1--------- ----- - -Size__3_Wats? Uquid depth --l"----------`---------Capacity------ Disposal Field: Distance from nearest well.'_-----_`Distance from foundation.---/0-----------Distance to nearest lot line._----------- l Number of lines..... Length of each line"-. ....`-__-....Width of trench.. - ------------------ oQ Type of filter material- C_ `.__-.-__Depth of filter material.... _---__--_Total length.... ...•.. .................. 0 ; Seepage Pit: Distance to neareA well------ rom foundation--- Distance to nearest lob line-.I._......-.. Number of pits----IdL�,__..-------Lining material�k.----. Size: Diameter----_ ` 1 saw.'.". " Depth. saw` rM Cesspool: Distance from nearest well ................Distance from foundation----------'``------Lining material------------------------------------- ❑ Size: Diameter-------------- -----------------------Depth.-------------------- ---------------------------- Liquid Capacity. gals. � r Privy: Distance from nearest well----------------------------------- ----------Distance from nearest building----------------------------------- __ ... 1 ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------------------------- -------- Remodeling and/or repairing (describe)---------------------------------- ----------------------------- -------------------------------------------------------------------------I------- ----------------------- i --------------------------------------------------------=----------------------------------------------------------------------------------------------------------------------=------------- ---------------------------- -- I hereby certify that I have prepared this app' ation and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reg ons the San Joaquin Local Health District. (Signed)..._ - - - (Owner and/or Con rector),- By:----------------• ------- -- - -- -_----:----------------------------------(Title)--------------- _ --------- -- --------------- - r (Piot plan, showing size of o , cation of system in rel tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY.--- - y ------------------------------------------------------------ DATE )-------------- = --- REVIEWEDBY----- -------------------------- -------------------------------------------- -- -------------------------- - - ---- DATE--•------------ -------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------•---------------------------------- --------- DATE-----------------------------------I----- ------------------- 1 . Alterations and/or recommendations:-- Z ' �'........--- h`S�}�� tri--:.- .pcap--------- ------------------- 1-1 ---------- -------------------------------------------•---•------ ----------------------•-----------------------------------------------•------------------------------------------------------------------------ ------------I---- ----------------------------------- ----------------------------------------------------------------------------------------------- -------------------------- ----------------- ---------------------------- -------------------- ---------------------------------------------- - - ----------------------------- - ---------------------------------------------------•-r -----------------,- ----------------------------- ----------"--------- ---------------- Y I= Z `�-� �� FINAL INSPECTION ----- iDate_"_.-.� -- -- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maxelton Ave. 300 West Oak Street 124 Sycamore Street 205 west 91h Street Stocklon,California Lodi, California Manteca;California Tracy,California ES 9 REVISED 5.59 3M 3-'63 F.P.CO.