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1-UROFFICE USE: �. ---------------------- -----------------------------------------.-----_-------._ APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------------- -------- -------_- (Complete in Duplicate) ` Date-Issued --_ ` ------- -- ---- -----------=. ,This Permit Expires 1 Year From Date Issued aZ Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein descried. This application:is made in compliance with County Ordinance No. 549, r , JOB ADDRESS AND). CATION--- - � � G Y Owner's Name = ----- ------- y ------------------- -------------------------------- = ?hone rT4J Address------------------_ _ I -----------------------------------------------•----------------.-.------•------------------------- Contractor's Nama -{----=--•---------t----------- --------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: ___ ___ tuber of bedrooms ____ - t ._ Number of baths ___I___ Lot size _____ Water Supply: Public system Community system F1 Private ❑ Depth to Water Table -------- ft. (_` Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy n y Loam ❑ Clay Loam ❑ Clay ❑ Adobe Iardpan ❑ Previous Application Made: (If yes,date------- ----------_)' -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.) Septic nk: Distance from nearest well_Zo-------Distance from foi/n tion__.!-! ____._ Mater' ! . - No. of compartments____-_____. Size___ ?( -- Liquid depth Cgo apacity----C _ . Disposal field: Distance from nearest well.-6-1------'Distance from foundation /40 _ __..Distance to nearest lothne -011f Number of lines_____________ __1_ .._____ --. ength of each line---------- - -- Width of trench._______ -- ii. Type of,{filter material . _ �epth of filter material_______ - -------.Total length----------- -------- --- Seepage Pit: Distance to nearest well __________ ___-----Distance from foundation--------------------Distance to nearest lot line--------------_-- ❑ ._Number of pits-------------------------Lining material---------------- -- ---Size: Diameter-------------- -------Depth--------- ----------------------- Cesspool: DisfaZe,f-om nearest well_________________Distance from foundation_------------------.Lining materia!__.---------------------------------- El _._____-___-_ _._______________.-❑ Size: Diameter---------------------------------------Depth ---------------------Liquid Capacity-------------------------gals.- Privy: _ Distance from nearest well____----____._!_ V) Distance from 'nearest building.-___.-______-----._ ❑ Disfance'to nearest lot line-- Remodeling and/or repairing (describe):--------------- ----------------------------------------- ---------------------------------- - ---------------------------------------------- -----------------=--------------------------------------------- ------------------------------------------•---------•-----------•----------•----------------------------------------------------------------------------- `11 1 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 'regulateof th Joaquin Local Health District. (Signed)------------ -- --�'--- C --------------- --------------(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). E �. a �j FOR DEPARTMENT USE ONLY -- APPLICATION ACCEPTED BY--------- ---------- ----------------------- ---------- DATE---------� ?7--� ----------------------- REVIEWED BY '-------- -------------------------------------------- ---------------- ----- DATE---- ' BUILDINPERMIT ISSUED--------------------------------------- -------------- --------------------------------------------- DA•TE- Alferati s s d/ r reco mendafions_______ _-__--_ - . � �_ -- --- - - -- - ----------- ---------- - --- - --- ._ ___ __________________________________________________________________________________________________________________________________________________________________________________________________________________________ FINAL INSPECTION BY: Cr;7c ----------------------- -- Date--------- �y�✓ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Slocktan,California 1, . Lodi,California Manteca,California Tracy,California r ES 9 REVISED 8-59 :4M.3-153