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a FO OFFICE USE, 4 APPLICATION FOR SANITATION PERMIT Permit No. ...fl_._... / --------------------------------------------------------- ------------------------------ ----------- - ---------- (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 descried. This application is made in compliance with County Ordinance No. 549. ,,,pp Z i JOB ADDRESS AND LOCATION----- / --- d---------�'------- ! ------ ------------- ��7a!?gle7v-A/---------------------------------------- Owner's Name-------------- -------- ---------------------- �7C ------------------------------------------------- Address------------------------- �.d L 4�' r' ~ --`-'----------- ---------- ------------------------------ Contractor's Name_________________ i Phone__ Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---- Number of bedrooms ,-- Number of baths __f__-_ Lot size -------455�____- _________________ Water Supply: Public system 91--l"Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: {lf yes,date------------------ -} No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material............-.-.----------.-------.--._-.-______- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth---------------- ---------Capacity----------------------- Disposal Field: Distance from nearest well_-_-_ _____Distance from foundation-__l__ei.........Distance to nearest lot line___- �__.__. UK Number of lines........ ._.______--__Length of each line____ _ . Width of french.--cO_4----------------- --- i Type of filter material----�_1NAG°/4e Depth of filter material---/ --------------Total length--------�--- --------------------- Seepage Pit: Distance to nearest well-------�'__--___-___Distance froin foundation_ -----..---.Distance to nearest lot line.... � Number of pits____-./-_______-Lining material___;F/X'O-l�Size : Diameter---R_�_"-----Depth-----o2�__--_____----- Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material--------------.---------.--.---__..._ ❑ Size: Diameter------------=-- ------- ----------Depth---------------------------- ---------------------Liquid Capacity----------------------------gals. I% Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------_----------.__._. ❑ Distance to nearest lot line,,=---------------------------------------------------------------------------- - Remodeling and/or repairing (describe):_____ - C ------- -_____ �1� ___________-__-_ ------------------------------------------------------------------------------------------------------------•------ --- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- -------------------------------•---------------------------------------•---------------------=----------------------------------------------------------------------- ------ --------- { 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, ari rules and regulations of the San Joaquin Local Health District. (Signed)------- ------------------------f _l _ l/ —------------------------------------------------------- ne and/or Contractor) •� (Title)___._ By: ---- ------ ---- ---- -- --------- ----------- ....... ---- . ............. , -------------------------------------- (Plot plan, showing size of lot, location f system in relation to wells, buildings, etc., can be placed on reverse side). M FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------aL-, -------------------- - --------------------------------------------- DATE-- --------- REVIEWEDBY------------------------------- - -------------------- ------- ------------------- ------------------ DATE-------- --------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------ ---------------- DATE------------------------------- ----------- --- -- -- - 1 Alterations and/or recommendations-------------- ---•---- ----------------------------•-----------------------------=----------------------------------------------------------------- a --------------------------- -------------------------------------------------------------- ----- ----------------------------------------------------------------------------------------------------------------------- I ----------------------------- --------------- ------ ----- ----- ----- -----------------------------------------------------------------------•-•-------------- ----------------------- --------------------------- ------------------------------------- ----------- --------------- ---------------------------------- ------------------------------------------------------------------------------ ----------------------------------------- i ----- ---------- ....... ------- ----- ---------- ------------------ ------------------------------------------------- --- ---------------------------------------------------- -------------------------------- FINAL INSPECTION BY:---.0 ------------------------------------------- Date- 7?;"......{ ------------------------- f SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Slocklon,California Lodi, California Manteca,California Tracy,California i r.P.C l7. 1