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FOR OFFICE USE: - --------- �f APPLICATION FOR SANITATION PERMIT Permit No. _ �......... ---------------------------- (Complete in Duplicate) 5--------� J f _ This Permit Expires 1 Year From Date Issued Date Issued ________ ____5 -------- ------- s�- -------- 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 OCATION_/ _-_Tn{i--.I_�---- !4 (_.__ -- ------ --------- -------IC, ----- `" - ---------- - - -e-------•-I....... ---------------------------------------------------------------------------------- --------------- Phone.------------ '-----------•-------- Owne>�s Na e__. ______ __ Address 1_ : -------- BB = i s � r cr Confractor's Name --------------- _...d,_,X------ - ------------------------------------------------------ Phone-----_----------•••• Installation will server Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1__>-,Number of bedrooms _�__ Number of baths-._L-.L__ Lot size ____ --------------------------- Water, Supply: Public system El `Community system ❑ Private Depth to Water Table ________ ft. t � Character of soil to `:depth`of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application'Made: (If yes,date------------,........I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND.,SPECIFICATIONS: (No septic tank or,cesspool permitted if public sewer is available within 200 feet.) ❑ Tank: Distance-from nearest well----------------- from foundation--------------------MateriaL________-___-_-______-______-_________-________- P No. of corartments_________________________ n Septic, P _ _-Size------------------------- -----Lipiuid depth--------------------------Capacity----------------------- Dispos' Field: Distance from nearest well---47iP0 -------Distance from foundation_____la--------Distance to nearest lot line-----_57_-_..___. ' Number of lines___:_-_--/-__---- -___Length of each line---L_f ?........_--------Width of french-.,.'Z _____.-________.__ Type.of filter'material___� r------Depth of filter material_-/__1.............Total length-----kqo..-.._________ Seepage Pit: V'DistanCe to nearest well----------------------Distan4te from foundation---------------------Distance to nearest lot line_________________ ❑ Number of pits----------------------Luling material-----------------------Size: Diameter-----------------------.Depth_--__-___--___________-____------ e 1 fi Cesspool: Distance from nearest well----------------_Distance from foundation------------------- Lining material_.____--_-____________.____._______. Size: Diameter----- ----- --------------------------De th----------------------------- ----------------------Liquid Capacity gals. P'rivy::; '_Distance4rom nearest well-------------------------------------------------Distance from nearest building-----------------------------------------. LS ❑.f Distance to nearest lot line-----------------------------------------------------------------------•------------------------------------------------------------------- -Remodeling and/or repairing describe :____ __ ______________ ••--------------------- -•------- -' r.?p t -------------------------------------------•---------------•---------------------- ------ --- -------------- ------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law and rules and regulations of the San Joaquin Local Health District. ( {Signed) --------------- ---=------------------------------------ ---------------- and/or Contractor) By:--------------- ---------- - --- - -< -- -------- (Title) r (Plot plan, showing size of lot, location of system in relati to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY : APPLICATION ACCEPTED BY--- l ----------------- ---------------------------------------------------- DATE----S------ --1"---(-- --- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE----------------------------------------------------------- BUILDING PERMIT ISSUED--------- ------•-------•-•--------------------=--------------------------------------------=------•- DATE---------------------------------------------- -------------- Alteretionsand/or recommendations------------------------------- ------------------- ---------------------------------------------------........---_-------------------- ----------------- ---------- ------------------------------I --••-•--------------------=-----------------•------------- --------------------------- ------------=----------------------------------------------------------- ------------------------------------------------------------------------------ ------- ----------------- - ------ -------- •--•---------------•----------------•--------------------------- ------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:_ ---------------------- Date-------z> -------�- -----•S .w SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E.Hazelton Ave. 300 VYe'st'4ak Strreeet� � .: a 124 Sycamore Street 205 West 9th Street Stactcton,California Lodi,California ' 1 Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'S3 F.P.CO. l S