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FOR OFFICE USE: -- - -- - -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..... ----- ................... Com lete in Duplicate) licate P P� ) .................................._...._...._---------- This Permit Expires 1 Year From Date Issued Date Issued ._0 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. Z3 _$ ,1✓' ' o JOB ADDRESS AND OCATION....---...af .............. -- -------------- ' �"`�` hCc Y`"-"" �°�` ----- '"^` Owner's Name---------- - --------- ---- --- • --- --- -• -- --- ------------.... :. ----- Phone------------------....----------•--- Address--•- --- I�`5 ...... ...,. ---- Contractor's Name----- ---- -•--- e ---------------------------- ------------ Phone-------------------..--_ Installation will serve: Residence [t, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---- Number of bedrooms -5--- Number of baths _,4-- Lot size ------I..C't.l-------------- ----------------------- Water Supply: Public system ❑ Community system ❑ Private l-'1 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [Adobe ❑ Hardpan ❑ 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 availa6le within 200 feet.) Septic Tank: Distance from nearest well---nK49/_.Distance from foundation---1,0-°_.-----Material-.-.-C_&_j A—....................._._-.. No. of compartments---------Y-----------Size- � 9- .s_____Liquid depth--------�.�------------Capacity..l�r Disposal Field: Distance from nearest well_._-O - Distance from foundation-----Q�.-----Distance to nearest lot line-,.`-/---------- C�y Z/ Number of lines................4 ---------.------Length of each Width offrench------------------------------- rc, Type of filter material--_,,.{_ -AC ------Depth of filter material----J �1."_.......Total length...-r Q A---------------- 44 r See Pit: Distance to nearest well------Z_VP......Distance fr m foundation.-.J..IJ..-...--..Distance to nearest lot line-5 ...... ----._Size: Diameter------ - J:'..._--De th-....P__.S................... Number of pits..._._..'_-__._____.Lining material-... .. _. ,3 p Cesspool: Distance from nearest well-----------------Distance from foundation----- ----- Lining material--------------.-.._- ---------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building___._.-___-___.______._.___._.._.__. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------•--------------------•--•--------------- • 1 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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health Distric'F.'(Signed) L ------------------------------------------------ ------------------------- --------- -------------------------Owner and/or Contractor 8 Title - Y= ------ ---------{ 1 (Plot plan, showing size of lot, location of system in relatio to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.. ------------------------------------------------- DATE-......_= � --. REVIEWEDBY---- ------------------------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------•---------------•---------------------------------------- DATE--------- --•------•----------------------------------------- Alterations and/or recommendations:-------------- --------------------------------------------••-------------•-------•------------•-•--------•-------------------- ......------------------------- -------------------------------------- ---------------------------------------------------------------------------------------------------------------------•----•--•------------------------------------------ ----------------------------------------------------- FINAL INSPECTION ------------------ Date. ". = ..-Cz-,.I' ------------ ----- --------- ---- ------ SAN --- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockfan,California Lodi, California Manteca,California Tracy,California E5 9 REVISED 6-59 31A 3-'63 F.P.EO.