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FOR OFFICE USE: Permit No. APPLICATION FOR SANITATION PERMIT ............. . (Complete in Licata t✓ ----------------Evii---- _________________ This Permit Expires 1 Yew from Date Issued Date;Issued _:._ �- Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described.. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND C4LOTION......-------- J _.... .............. - ---------- ------------------------**,-,*........ ----- -- --------•-------- Owner's Name / . ?.Address------------------------ . . --•- •-----............................................................. -...--------------------•------------•-----•---------------------------•----•-- --------- Phone.. .....Contractor's Name :. Installation will serve: Residence [ -'Kp_artment House Q Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ./___ Number of bedrooms_,. Number of baths ,/..... Lot size I .......................... Water Supply: Public system ❑ Community system ❑ Private �pth to Water Table/Solt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Cla ❑ Adobe(-i],..-Hvfiapan 0 Previous Application Made: (If yes,date---------_-----------) No New Constructiop: Yes [ o HA/VA: Yes, ' No Q TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiflied if public sewer is available wNhin 200 feet.) Septic Tank: Distance from nearest well.................Distance from foundation._..................Material................................................ PsNo.,of compartments_._..', Size..............................Liquid depth.........................4 Capacity. -. Disposal Field Distance from nearest well_________________Distance from foundation....................Distance to nearest lot line................. { jy Number of lines-----------------------------------Length of each line ...._.._....•___. Width of trench....................... l Type of filter material.........................Depth of filter material..__._--_..._ Total length........ ._.. t If Seepage Distance to nearest h,,,„ ,.__—Disteace-from.foundation,,� ....... �_.--_, e. _. Distance to nearest lot line Number of pits..--- ......— Lining material. �y-t ®_.Size: Diameter_2U��_._...__Depth_ - _.., 2 Cesspool Distance from nearest well.................Distance from foundation......:...........ening material--------- ----------------------- El __ ___•_--.❑ Size,,Diameter----- --------------------------------Depth_ Liquid Capacity: gals ;Privy: Distance from nearest well.-..-.............................. ........Distance from nearest building......_._ .s.._.....,.,...........::... ., ❑ Distance to nearest lot line. ---- . -- -•-- -- •---- ------ -- ---- ...-.0-- •. ......................... -•--•- Remodeigng and/orrepairing (describe "' -----------------. --• ............ -------------------•--••----•-..._......-•-- -•---•......--••••---•--••--••-• ------. .......:_ ....•--•--•-•••--••----•-----•---••.. .. ••-•---•---- ------------- ------------•--.----- •--•-- •---••-- ......-- -- •---•- •---- ------.. ------------------. -----• . .. ..................... I hereby certify that I prep 's application and that the work will be done in accordance with San Joaquin County ordinances, State laws, es an "ons of the San Joaquin Local Health District. (Signed) ----------- •------ rea�anrtd/or actor) g Title ------- ---- ------------- ( ) (Plot plan,showing size of lot, tion of system in relatio ings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY...._ -... ``—............................................... DAVE..----- j 61/. ................. REVIEWEDBY.......... ..--------- •---••---•----•.....,. . ---•--. -- ......•. . ••-•--•-••••. •-•-•• ...... DATE--••....................... BUILDING PERMIT ISSUED.___...................... _____________ .................... rt ._, DATE t i :Alteration1,1110/or recommendations: 4 t-- -- ..................�"------ _ ---• ._._._../t '._.. _ moi - t. FINAL INSPECTION BY: L �.. ILI Date ��_ SAQULOCAL HEALTH,,CSISTRICT 1601 E.Haxdfon Ave: 200 West Oak Stew 124 Sycamore Street 205 West 9th Street Stetkton,California Lodi,California Manteca,California Tracy,California E8 9 111MIRED ®-SV 3M 3-'63 F.P.CO.