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FO OFFIC USE: _ �. ------ ----- -- - -'� __-- �l APPLICATION FOR SANITATION PERMIT Permit No. •- 7 -- ---------------------------------------------- (Complete in Duplicate) �.� ..- is Permit Expires 1 Year From Date Issued 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 LO AT ON 1 --------- ----------------------------------------------------------------------------------------------- Owner's Name__.__B0% / ------ Phone----------------------------------- Address_-- - --- - ------ � •�!� �--------- --- Contractor's Name f� Phone Installation will serve: Residence j Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel/E] Other ❑ Number of living units: 1_____ Nu er of bedrooms .__Z..PJumber of baths-.____ Lot size ____ __/'- __, _ _____-____ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe P—rfa dpan ❑ Previous Application Made: (If yes,date--------------------) Noew Construction: Yes [�i�o—❑ FHA/VA: Yes ❑ Note-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) `� _ Material .-___ -_ ,p_ Septic Tank: Distance from nearest weli---�tance from foundation___________ _. � .��7.r1r__C__t�________. [i� No. of compartments------- (;1-_--Liquid depth___--- /y-------CapacitY--Disposal Field: Distance from nearest well-____�istance from found tion______ _ d Distance to nearest,lot line.---T— Number �} ,l ;-- [i}� Number of lines______""]w -__ _ 3 Length of each l�ne�__ ______�_i'.?'--/-?Width of trench....o1_40__��------------- Type of filter material___ of filter material_- _ _ ____--Total length______ ____l_. __-- Seepage Pi.i-' Distance to nearest well----_--. stance from foundatior�--__�____�____.Distance to nearest lot line___'-c_J____ Number of pits.__--/---------------Lining material-_-_ 3-ti"_. r'Size: Diameter__.� ----------Depth---- ,`__L__ _ Cesspool: Distance from nearest wel!-----------------Distance from foundation--------------------Lining material-------------------------------------- n Size: Diameter------------------------------------- Depth----------------------------------------------------Liquid CapacitY- - ------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building -_-______---------------------.---------. ` ❑ Distance to nearest lot line------------------------�--,,--- --�-------------------------------------------------------------------------- --------------------- ---- Remodeling and/or repairing (describe)=---------------------- -r2 :.•mss ------- r rrT: -------•----•--••---------_____-------------••--- -----•------------------------------------•-------------------•------------------------------------------------------------ -------------------------------------------------------------------- ---------------------------------------------------•--------------------------•---------------------------------------------------••----------•------------------------------------------------------------------------- - 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. (Signed)-------------------------------------------------------------------------------------------------------------------- ---------------------------------------------(Owner and/or Contractor) gY:---------- ---------------------=---------------------------------------------------------------------------------------------------(Title)------------------------------------ - - - --------.-------------- (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 APPLICATION ACCEPTED BY �_ ��`��-------------------------------------------- DATE ` REVIEWED BY----- -•-------- DATE------------------------------------------------------------ ------------------------------------- -------------------------------- BUILDING PERMIT ISSUED._....----------------------------------------------------•-•--------------------------------------- DATE--------- ----------------------- -------------------------- Alterations an�Lor recommendations:__ -<-f : '- - -- .s-:4 :--_-_1-4— ____ _�---------------------------------- � . ---------------- -------- --= ' -- �-- --- -----•------------------------------------ - ---------'---------'---� f---------••tib•-----------•-�-------�---'��-�----``----��z•'-'--�t'ca—,�-� --- c- --------------------------------- --------------e---- ------ --- fi - =f ---------------------- FINAL, INSPECTION BY------------------------------------------ ------------------- Date --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocktanr California Lodi,California Manteca,California Tracy,California ES 9 REVISED g-59 SIM 3-'S3 F,P.CC.