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VUR OFFICE USE: --- --- p ... ................. APPLICATION FOR SANITATION PERMIT Permit No. - � ------- ----------- ----------- ------ (Complete-in Duplicate) - & _ ........ This Permit Exi2ires I Year From Date Issued Date Issued _Z�-77�1��_�� Application is hereby made to the San Joaquin Local Health District for a permit f onstrutt and install the work herein described. This application is made in compliance with County Ordinance No. 544. JOB ADDRESS AND LOCATION---- ---- --- � ��—yF'�. V- -- - - -- -- ------ ------------ Owner's Name - ------ ----------------------------------------------- Phone--•---- -----------•-------•----- Address------------ --------- Contractor's Name Installation will serve: Residence partment Ho e ❑ Commercial Trailer Gourt ❑ ❑ Motel [I Other ❑ Number of living units: _./_._ Number of bedrooms_ Number of baths.__/__ Lot size __ ---- _--- Water Supply: Public system E] Community system E] Private epth to Water Table --------- _ f# Character of soil to a depth of 3 feet- Sand ❑ Crave) ❑ Sandy Loam 0Y(5a`y Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Applica+ion.Made: (if yes,date__.-__-__-------- ) No ❑ New Construction: Yes ❑ No �HA/VA: Yes ❑ No ❑` A TYPE OF INSTALLATION AND SPECIFICATIONS: S``` (No septic tank or cesspool permitted if public sewer-is available within 240 feet.) Se c T - Distance from nearest well________________Distance from foundation__.__--_____._..__ Material _____.._._----_ - No. of compartments------- --- ------------- ----------- ---Size-------------------- ----- -----Liquid depth...------ ---- --- _ Capacity--•-------------------- " D osal i Distance from nearest well. r ��` _._.__Qistance from foundation._.._ O-__.- Distance to nearest lot line__i� __ J Number of lines____� ____ Len th of each line_..._ el - g -- Width of trench - -------------- � 'yQ! Type of filter material Depth of filter materiai_._.-�_�_�-�_____-,Total length---------- O- ' ---------------- Seepage Pit: Distance to nearest well______________________Distance from foundation___.-- _____________Distance to nearest lot line-----____.___._- ❑ Number of pits__-'--_-_,_--___�-Lining material_____________ foundation-- ........ Size: Diameter------------------ ----Depth---------- ------•------- ------- Cesspool: Distance from nearest well _� �Distance from foundation._.._I- _----._. ..Lining material _________ _________.__ ❑ Size: Diameter- ---- ----- ------......... -------Liquid'Capacity---------------------:------gals. -----------------------+------- Privy-, Distance from nearest welt....... .......... .. � ................ ...........Distance from nearest building Distance to nearest lot line _..____._.._._ . g ------------- ---------- ---------------------------------------------------------------------- ____.._j and/or repairing (describe):____..__-____. •�. ld - -------------------- - = '" ---------- ------------------------- - - - _144� r 1, .� hereb certif that I have ------ ----------------------------- Y y prepared this application.and +hat +h work will be done in accordance with San Joaquin County ordinances, Sate law , and rules and regulations of +he San Joaquin Local Health District. C' J - r (Signed) -, ----- (�ior Contractor] BY:--•-------------•-----------•-- Title t - - ---- ---- ( ] -- (Plot plan, showing size of lot, location of system in relat n to wells, build! gs, etc., can be placed on reverse side]. DEPARTMENT USE ONLY APPLICATION ACCEPTED By'_------- ---- - ------------- --------------- ------------------------------ ------- DATE. 0^S' -�_. REVIEWED BY------- f -------•------------ - ------------ -------- DATE-- •---------- --------------- --- ILDING PERMIT ISSUED ------ - `-- -- t - ------------ Alterations and/or recommendations:_______. i .......... -----------------•---- ------------------------ ............... -------------------------------- ----- ---------------- --------- ---------- - - FINAL INSPECTION BY:_--__- `lv- v-7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street Stockton,California Lodi. California Manteca,California Tracy,California E.H.9 2M 1.67 Vanguard Press i