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FOR OFFICE USE: ------------------ ----------------------- 3 --------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .._----� ---r_•-----••- ------------- ---------- ------ �M --- -- -------- ------ [Complete in Duplicate) Date issued -------------- -----------------i-- --- ------ -_._ - - 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 alication pp is made in compliance with County Ordinance No. 549. N ;rgjjl j�5 7 JOB ADDRESS AND LO TI :---- -_----- ` l !`7`' ="( `. a Phone / ----- ------ ------- -------------------------- AOddress amei; ----- --7------11 - Address Name--------• , �--�..._ -- 1� Phone. Installation will."serve: " Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.-�___ Number of bedrooms _ Number baths�f__-. Lot size ____- ----a- t----------------------•------- ` Water Supply• Public system ❑ Community system ❑ Private Depth to'Water Table ____.___ ft. t Character of $ it to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan Previous Applii}ation Made: (If yes,date--- ---------------) No ❑ New Construction": Yes ❑-- 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.) Septic Yank: Distance from nearest well.._�L�___.._Distance fiom7 fpundatiori_____ _ ________Materia!-_____-�-r-----.-----------. Z' ��-Liquid depth----- -----------.Capacity _r No. of compartments Size._-_ - + pispo Field.. Distance from nearest well_._.__.�_.�___...Distance from foundation----- to nearest lot line_.__- _.__. I Length of each line-3-14- - N �idth of trench---_._" __ ________________ Number of lines__._...____._ g Type of filter material __ �J__--.--_Depth of filter material___.;_._ --_Total length-- ._---/_,a/_,ae---------------------- rn t r Seeps dPlt: Distance to nearest well------ 4)------Distance f ,,-�fo�ndation_:_._.�_�____._.Distanle to nearest lot Gne_�__._.__ Number of pits----.../-----------Lining material-_-_ -.Size: Diameter.-..�-g._._......Depth_-_- ----------------- 11 nCess110- Cesspool: pool: Distance from nearest well_---------------Distance from foundation-.----___,__.-------Lining material----...------------------------------ 0 ElSize: Diameter------------------------- -----------Depth-------- ------------------------------------- ----Liquid Capacity----------------------------gals. 3 Privy: Distance.from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 150 ❑ Distance to nearest lot line------------------------- ---------------------------------------------I---------------------------------------- ---------------------------- Remodelingaln d/or repairing (describe):----------------- ----------------------- ------------=--------------------•-------------------•------------------ ------------------------------------- -- ----------- ----------------------------------- 1M ----------------------------------------------- I hereby }certify that have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws nd rules and regulations of the S n Joaquin Local Health District. (Signed) ---------- -1 � - - and/or Contractor) By=-----��---------- -•---- �( �1' (Tit e)-- {Plot plan, sh swing slz of ot, location of system in r lafion to well .buildings, etc., can be placed on reverse side). �E FOR DEPARTMENT USE ONLY . APPLICATION ACCEPTED BY - -- -- -- -------- --------- ----------------- ----------------------=-------- DATE---�---------------- -/-------------- ---- ---- REVIEWEDBAY----------------=---------------- -------- -- ---- ----------------- -_-------=_------------------------- DATE----- ----------------------------------•------------------- BUILDINGPERMIT ISSUED---------------------------------------------n--------- ------------------ -------------------------- DATE------------------------------------------------------------- Alterations anl)/or recommendations:------------------------------ ---------7------------------- -------------------------------------------------•---------------------------:-----------•------- '----------------------- -------------------- ------• --------------------------------------------------------------- ---------------------•• ------------------- -------------------------- -------- - ----------------- ---------------------------- --------------------------------------------- --------------------------- I W , - ----------- ------------------------------- --------•------------ -- ---------- ----------- ------------------------------------------- FINAL INSPECTION BY: - -- Date-_..o-�.- --6 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street St 1`kion,California Lodi,California Manteca,California Tracy,California t f ES 9 RE;V IS EC]`I 2-59 3M 3-'63 F.F.100, S � I