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FOR OFFICE USE: --------------- --------- ------ ----.............. ............................... APPLICATION FOR'SANITATION PERMIT Permit No. I ----- ---------------- f (Complefe•in Duplicafel l Date Issued - ------------- --- This Permit Ex Cres 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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--.---_r�/lS" Owner's Name--------V_ _,----�- ---- -- ----------------------- Phone-�-�/ Contractor's Name------- --- -- -- --- �/ ---- ---- - ---------------------------- •--------------- Phone_ -� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑, Motel ❑ Other ❑ Number of living units: -. _ Number of bedrooms __e,-2-Number of baths-I- Lot size �----------------- Wafer Supply: Public system Community-system ❑ Private ❑ Depth to Water Table.'-9_ ft Character of soil to a depth of 3 feet- Sand E] Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe j' Hardpan ❑ Previous Application Made: (if yes,date---------- . -..... ) No ❑ New Construction: Yes ❑ NoX FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (J�� (No septic tank or cesspool permiffed.if public sewer is available within 200 feet.) 1 "Se Tank: Distance from nearest weEf___---------- Distance frorn foundation--_----------------Material .... No, of compartments_.._ --- Size--------------------- ---------Liquid depth--------- . --- -------__.-.-. Capacity --------- ------I Dis sal Field: - Distance from nearest well-----------------Distance from foundation----------------.__.Distance to nearest lot line-----_-.-... Number of lines...------------- -----Length of each line-- -=- --- - - -----------.Width of trench------- ---------------Type of filter material_____ _________ ______Depth of filter material.---._.------________--Total length-------_.-------_--.----------_---Seepage Pit: Distance to nearest well ; -�t�_.Distance rm foundation--- ]y�--:U_ ' DistanEto nearest lot line.s_!lNumber of pits--- -_---/_-_------_Lining material Size: Diameter_ - -. -_.Depth-.- ---------- ----Cesspool: Distance from nearest well ----------------Distance from foundation_-..-.--___---.- Lining material-,-------------__----- _Size: Diameter- -- --------- --__ .._ Depth- - Liquid Capacity ------------ -------------gal Privy: Distance from nearest well------- -------- _-_'--. -------.._Distance from nearest building ❑ Distance to nearest lot line------- --------------------- Remodeling -------------------Remodeling and/or repairing (d scribe):_ 'l�2 - ,p --- ------- / --------------------------- 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 ules nd regulations f the San Joaquin Local Health District. (Signed]_.(- - -..rte�: ------ (Owner and/or Confractor] SY - g - -(Title)-- ------- -------- ----- ----------- P of plan, showing size of lot, lace+ion of sys+em in relation to wells, buildin s, efc:, can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.-. - ---- ------------------- ---- -------------- DATE..--------- REVIEWED / BY-------------------------------------- --------------I----------------- - ----- DATE--- ------------ UILDING PERMIT ISSUED-------- -- ----- - ------ DATE - ------------------------------------ Aterations and/or recommendations:--._- _.......................... FINAL INSPECTION BY:.._- --- ---------_------------------------- Date.,-. - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 west Oak Street 124 Sycamore street 205 West 9th Street Slockton,California Lodi. California Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard press