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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued -"",.-___"_"""""- "`This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. ' R � JOBADDRESS AND LOCATION-------- ---- -7------- ----------------------------------------------------- -------•--------- -•-------•---- Owner's Name------------------ Phone.. —{� Address. . ~' --�------ -------------------•------------------------------------- ---------.----------. ---------------------- , -�•,---- Contractor's Name• - ,=-_-------•--------------------------------•---- Phone_, _ .�V Installation will serve: Residence Apartment House ❑ ,Commercial ❑ Trailer Cdurt ❑ Motel,❑ Other ❑ Number of living units: _-/-----Number of bedrooms A__ Number of baths -/____ Lot size __.__��"�� _-•---------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ElClay Loam [] Clay El Adobe a Hardpan E] Jtr Previous Application Made: (If yes,date----------- --------) No.K New Construction: Yes No ❑ FHA/VA: Yes E] No 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank`or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance nearest wellDistance from foundation_-_"________.- F , s --- ---------------------------- Noof compartments ___.__.__`_______ --------------------------B - --------------Lquid depthCapacity____________________ Dispos Field: Distance from nearest well_____ ------ -.Distance from fou"ndation--------------------Distance to nearest lot line___---__-________ Number of lines-=-------------------------- ----Length of each line---•------------------------- Width of trench---------- --------------"--------- R, �i�Ls/w Type of filter material_________________________De.0h -of filter material------------------------ otal length____.-_."_______.:.____________.._________ 1. .2. _ w ...j. .- � - .. .a. Pl. .. ....�. Seepage/fPi`t�� Distance to nearest well________________"_-__Distance from foundation____-_._____....___.Distance to nearest lot line_______ Number of pits-------'--------------Lining material-_- ------------_�----Size: Diameter----------------- -__.`Depth-------- ----------- -------""""-. Cess p�ol: Distance from nearest well-_______________'Distance from foundation_____-____________.Lining material------------------------------------- Size: Diameter--------- ------------------------ Depth Liquid Capacity gals. \� Priv Distance from nearest well-------------------------------------------------Distance from nearest building----------------------_....--------._----- � . rice to Weare_ sty of line------------------------------------------- - - . Remode ung and/or repairs (d'escribe) ..�'� •- -- ----- ------ -- t x ----------------------•------------------ -- 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 and regulations of the San Joaquin Local Health District.. r (Signed)------ 1.. - ------- ------------- ------------------------------------------------------------------------(Owner and/or Contractor( `By---- -------•------------------------------------- -------------5------ --------1_--------------------------------------(rifle)-----------------------------------I--------------------------- (Plot plan, showing size of lot, location of system,inrelationrrfo wells,'buildings.etc., can be placed on reverse side). ' ;FO"EPARTMENT USE ONLY APPLICATION ACCEPTED By-_10 -t--------- ---= -----I "" � DATE REVIEWEb BY ; � ------__ DATE------------------------ I BUILDING PERMIT ISSUED - --------- ---------• --------- ----- ------------------- -------- ---------------- ---- -- = - - - ----1- DATE---------------- -------------------------------- Aler tions and/or recommendations: = --------"-----------• -"•---"------------- ---------------------------------------------- -------------- I -- ------- ------- ---- - ' Z- - Z- ` - -------- z¢ - -= �r- f - _ = ,, ---r--_...r ---- ------------------- ,�.�f �G'- 1 Ate- -�-c,.-�--�L f � �C�d tea- =fig- . � � s-.-►e• �.�-7`- -c.� -+: FINAL INSPECTION BY- Date. ----------- ---------------•---- ------- ----------------- ------ ;.. -rte?�-� -.•�'��st ��-.��Sr�co•��-�-e<=� �;. SAN JOAQUIN-LOCAL HEALTH DISTRICT' 134 Soulh,Amerlcan Street" 300 West Oak Street - —1'24 Sycgmore!S reel' 205 West 9th 51rae► Stoctct n'California Lodi,California Manteca,California Tracy,California FG-9 REV18E0 0-59 Ff^CM 2M 6.60 /