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APPLICATION FOR SANITATION PERMIT Permit No. .22..-// ...�... (Complete in Duplicate)��d F " d ' This Permit Expires 1 Year From Date Issued Date Issue ....._... Application is hereby made to t San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compli ce with County Ordinance No. 549. i JOB ADDRESS AND LOCATION ...... 4t-_ et___Z!�._,. �_y______ __' ,,n. ___ V_.___- Owner's Name,_ `ai. 1 .CI------------------- •--- Phone ..................................... ---------------------- Address------------------------------------ ----- --- - ----- --- .... 4 ............................................. Contractor's Name 'i t ./--------------------------------- ---------------- Phone.------------------. .............. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.. Number of bedrooms3--- __. Number of baths _2-- Lot size .-,V--A .....................I........__ Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table _ ._ift. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No P ---'New Construction: Yes fi�-lo ❑ 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_&t stance vfrom folf�ation._�.jJ....._.�_.. aterial_-___------- ._._�........ ........... ® No. of compartments --------- �__._____-_Size__000fh%ty-1--.... Liquid depth ------ 5_ --------------- Capacity�Q -- ,Disposal Field: Distance from neare wellpa--- ._.._ Distance from founds 'on..%Q '�'�+lrw Distance to nearest lot line ................. 00 Number of lines...--;- ._-_.__.. ------ _Length of each line_i.X4,2 ,e. t� _...Width of trench.44-1_ ..................... �.. Type of filter material..._: ... epth of filter material..._ ___Total length :-____-/__�__Q................. "'J Seepage Pit: Distance to nearest well ......................Distance from foundation .................... Distance to nearest lot line ...__...._.-__.-. ❑ Number of pits ...................... Lining material ----------------------- Size: Diameter.___-- ----------------------- Depth ----- .._...._.._._._--..._.__...- Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material -......_._..__.._.-.___._._______._.-. ❑ Size: Diameter -------------------------------------- Depth -------------------------------------------------- ._Liquid Capacity ---------------------------- gals. 0 Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building__,. _-._-_.______:_-.-__._...._.... ❑ Distance to nearest lot line ----------------------------------------------------------------------- -----------------•----------------•---•-------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- 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, and rules and regulations of the San Joaquin Local Health District. (� /f (Signed)--------------------------------- Vim--t---�l-�------- ---Y �r-`-+"w ---------- ---(Owner and/or Contractor) By:--------------------------------------------------------------------------------------------- -----_------ ___ ---- (Title)------------------------------------------------------ --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). APPLICATION ACCEPTED BY --,.4 --"`; ___ REVIEWED BY ....................... -------------- ---------------------------------- BUILDING PERMIT ISSUED ................................................... Alterations and/or recommendations: ----------------------------------- r47--------------------- ----------------------------------------------- DATE ------------------------------------------- ................. - -------------------------------------- DATE ------------------------------------------ ............. -------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------_ -----------------------------------------------------------------------I----------------------------- J ------ Date c «rte i- 47 FINAL INSPECTION BY:..-------- � ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Sfreef 300 Wes+ Oak Sfreef 132 Sycamore Sfreef 814 Norfh "C" Sfreef Sfockfon, California Lodi, California Manfeca, California Tracy, California ES -9-2M Revised 8-'59 F.P.Co.