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FOR OFFICE USE: ----------- ------------------------ ----------------=-- Permit No. .__C .11. -� --- APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- [Complete in Duplicate) �� Date Issued - __o3 _--=-- & --------------------------- -_ 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 described. _ p i with County Ordinance No. 549. �s-application i��a� m�� Dance p � ,�iaa'�l�d.�.r-------------• d-4-s---0'-�----�-0-�r-,---------- JOB ADDRESS D LOCATIO _�/- � Phone-----------------------•--------•--- N Owner's Name--=-- - --- -:---------------------- Address_.. `.--------------;----------- --------- - - ----- Contractor's Name f Phone --------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial [�Trailer Court ❑ Motel ❑ Other ❑ a •---- ------------Number'of living units: Number of bedrooms�l-- Number baths .'_�- Lot size -____ �-��-�--- Water Supply. Public system ❑ Community system ❑ Private Number bat to Water Table -------- ft. - Character of soil to a depth of 3 feet: Sand E] Gravel ❑r..Sandy Loam [] Clay Loam Clay ❑ Adobe❑ Hardpan Previous Application Made: (If yes,date---_-------_----.--1 No [-INewConstruction: Yes ❑ No E] FHA/VA: Yes ❑ No , TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ____ - o Seank: Distance from nearest gDistance from foundation..../°.----_----.Material __._-fi --- --------------------- No. of compartments.--------Y---------- ---Liquid dePth------1 -- ---------- Capacity it r DisField: Distance from nearest well-_--_�4_'fDistance from foundation_..--1_U___-------Distance to nearest log po line-s____.._ __. Number of lines---------------I----.--------- ---Length of each line------J.QCt-�- -------Width of trench.--`y-.le-----------------------� Type of filter material--------$X ___-._Depth of filter matenal.__I -------------Total length-----I��_----__.-_---____-------:- 01 Seep e Pit: Distance fo nearest well-----1QU.I-,,'.----Distance�m foundation__1_V.-------_-_.Distance to nearest lot iine_S----_--_-. Depth----- ------------------ t� Number of pits----------- Lining material-__ 11 .---.- Size: Diameter-____�?6 Cesspool: Distance from nearest well-----------------Distance from foundation-_-----------------.Lining material__________ ___ �. --Depth------------------------------ ---------------------Liquid Capacity-- ----------------- 9a ❑ Size: Qiameter Privy: Distance from nearest well ------------------------.----------------------Distance from nearest building----------.----------------------------- ..o El to nearest lot line__- W --------------------- - ------------------------------------- fr. ` Remodeling and/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 j ordinances, State law and rules and regulations of the San Joaquin Local Health District. I [Signed] -----------------------------------------------------------(Owner and/or Contractor] (Title L --- - ----------. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side. FOR DEPARTMENT USE ONLY DATE----DATE APPLICATION ACCEPTED BY---- -��'�'•�-'��--~ � _`__ ''' -------------------------------- - ---------------------- REVIEWEDBY----- --------------------------- DATE------------------•---------------------------------------- BUILDINGPERMIT ISSUED---- ---------------------------------------------------------—-------------------------------------- DATE---------------------------- -------------------------------- Alterations and/or recommendations:----------------- --- ----------------• ------------------------------------- -------------- ------------•---------- -• ---------------- ------------ -------------------------------- - ------ ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ --- --- -- 4 " -.�., ..,:�. _ Date ---- - T -------------- FINAL INSPECTION BY:..."_,/�.-_- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Naxellion Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stocklon,California Lodi,California Mantecar California Tracy,California F.p.0❑.