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APPLICATION FOR SANITATION PERMIT Permit No. ..____ 1 - G '{Complete in Duplicate} 9 Date Issued Application is hereby made to the SanJoaquinLocal Health District for a permit to construct and instal the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION !�'� ------------- ----- - ----------.------------------------------------------ Owner's Name--------71 ' �?l -'•------ ---.-. Phone---------------------- 5 ---- � ,�-- --------------- Address - s Contractor's Name.. ' -- ----- -------•---------------`--------- Phone----------------------------------- Insfaliation will serve: Residence V11"'Apartmerst House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __ Number of bedrooms --- ._ Number of baths ._/--- Lot size _X-MAP— ------------------------------ i Water Supply. Public system e-oc"ommun'ity system ❑ Private ❑ Depth to Water Table A_ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: Yes ❑ No 43 New Construction: Yes ❑ No P�— FHA/VA: Yes ❑ No n--- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if LL ��public�� sewer is available within 200 feet.) 0 Septic Tank: Distance from nearest well.dl Distance m fouundafion__A�--__-._.Material-rI&_� __ No. of compartments-----p?-----------------Size��-X-- VQ----Liquid depth_ -- --�- p y-------------� ¢ Ca acit �°4 '^.. Disposal Field: Distance from nearest well-4ry,101,15istance from foundation--_054?--------Distance to nearest lot line__ 4-__--- Number of lines--------- _-_ ___- nth of each line-_-- -_ Width of trench._-- !j Type of filter material- � Depth of filter material---_- le- ..Total length------- f,�._�--------------- Seepage•Pit: Distance to nearest well_�.',?24*P�__._'_bistance fr my oun tion...:_ _A!9_..__.Distan� to nearest lot line_ _ _______ [ � Number of pits------/-----------Lining material_ iZe: Diameter__.,ZJ___"____.Depth-----v?.Q__________________ Cesspool: Distance from nearest well-----------------Distance from jpufidation.-------------------Lining material--------..-.--_._-_-.-----_---__--_-- ❑ Size: Diameter------------------------- ------Depth-------------------------------------------------.-Liquid Capacity----------------------------gals. Privy: Distance from nearest well___________________________----------------------Distance from nearest building----------------------------- _--_-_-.__._. ❑ Distance to nearest lot line-----__________i------ i - --------- ------------------- 4i Remodeling and/or repairing (descrii�e)_--------------/_LG&4f _ _ ------ -- - - - ------ --- ---- - -- --------------- ---------------------------------------------------------------••------------------------------------------ ----------•--I---- ----------------------------------------------------------------------•---------------------•-----------•------ --------------------------------------------------------=--------------------------•--------•------•-•-------------------------------------------•----- '---------------------------------------------=------- -------------- 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, an rules and regale+ion of the San Joaquin Local Health District. (Signed)------------ -- -- - --------- ------ - - -------- --------------- By:--------------------- -------------By:---•-----------,•---.. ---------------- -• -- ------ ---------------------------------------(Title)-- — ---- ----------------- (Plot plan, showing size of lot, loca ' of system in relation to wells, buildings, etc., can be placed on reverse FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- ---- ----_- - -----------------=--------. DATE--------------- -------------- REVIEWED BY------------------------------------------ - --- ------ DATE ''5 BUILDING PERMIT ISSUED------------------- --- -- ----------------------------------------------------------------------• DATE---------W ------------------------------------------------ Alterations - ---- Alterations and/or recommendations------------ - ----------------------------------------------------------------------------------------- ---------------------•-------,...----------------- c� - -------- � l��r„ r- Cac�2� ------A/02�---------/7-G1Q-S ------------- -------- .-. _ -------------------------------------------------------------- -----=----------------------------------------------------------------------- -------------- ----- ----------•- ---- - -- --- ----------- ----------------------- ------ FINAL INSPECTION BY: � -= Date - --�7---------------------------- r AN JOAQUW LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stack+on, California Lodi, California Manteca, California Tracy, California ES-9-2M Revises 1.57 F,P.CO.