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FOR OFFICE USE: - ------------------------------------------- ------------- f --------------------------------------- "-------------------------- APPLICATION FOR SANITATION PERMIT Permit No. 2L,:2 ---------------- --------------------- - ----- (Complete in Duplicate) i; - This Permit Expires 1 Year From Date Issued Date Issued _______�_ 1,6 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appkication is made in compliance with County Ordinance No. 549. '� x:375 .10 JOB ADDRESS AW LOCATION-t � _ r! ."_ ,�-. Q� 19 If—!(a —YO Owner's Name- ------ -------- Phone------------------------------------ Address"_. ..._. -- ' r� ------0----- -=---------- Contractor's Name----- ao_�,_w.. "- -•- - -------- Phone....................... Installation will serve: 'Residence [Apartment House ❑ /Commercial [—] Trailer Court ❑ Motel ❑ Other ElNumber of:living units: J---- Number of bedrooms _e Number o baths /----- Lot size ____.___ __ ______ ____ ______________`_-_-_--._-_-_ Water Supply: Public system E] Community system Q ,Private _Depth fjeWafer Table -------- ft. Character of soil to a depth of 3 feet: , Sand ❑ Gravel'E] 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: h (No septic'tank or cesspool permitted if public sewer is available within 200 feet.) Septic- nk: Distance from nearest well a�d______Distance from foundation__1-0—.__._...MatenaL..._-C 1�-- ---_____.............. No, of compartments---__"7.�--------------Size-4'.d.`W-T'XXS .Liquid depth----q--s---------------Capacity.( 44._ _-__ Disposa f=ield: Distance from nearest well---SO.1.----Distance from foundation.V--_..-___-Distance to nearest lot line__-___- ---- C> Number of I•snes--."--"_-3____________________Length of each line-_.__--"4`p�___-----_"-.Width of trench.____--___-______________ W „ Type of filter material----- ---------Depth of filter material-------1-4.---------Total length--------- _-"_________________ Seepage Pit: s Distance to nearestwell----------------------Distance from foundation--------------------Distance to nearest lot line--------------- r � ❑ :, Number of pits------• -----------Lining material---------- ------ --- -Size: Diameter-------------- --- ----Depth-- -- -------------------------- ;''' 'p Cess 001: r. Distance from nearest well---------:-------Distance from foundation--------------------L-ming material------------------------------------- � ❑ Size: Diameter ------------ -------_.Depth Liquid Capacity gals. Privy, Distance from nearest well-------------------------------------------_-----Distance from nearest building"""""""""-.---------------._._.-.__----- ❑ Distance to nearest lot line- --- --------------------------------------- ---------------------------------------------- --------------- -- ------- -------- ---- - Remodeling and/or'repalring (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 District. (Signed)---------------------- ----------•---------------- - - ------------ -----------------------------------------------------------.--,c4OMr and/or Contractor) w....� BY:---------------- ----------------------------------------------(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-------- ----- ----------------- REVIEWEDBY---- ----------------------------------------L-------------------------------- -•---------------------------------------- DATE----------------------"----------------------------------- BUILDINGPERMIT ISSUED-----------------------------------------------------------•-—-------------------------------------- DATE------------------------------------------- - -------------- Alterations and/or recommendations---------------------------------------------------------- -------------•-------------------------------•---------------------------•--------------------------- I -------------------------------------- ------------------- ----------------------------------- ----------------------------------------------------------------------------------------- ------------------------------------- FINAL INSPECTION BY:. � !J .t/�-1 .----- -- Date l-._ t SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E.Hazalton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocklon,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6.59 3M 3-'63 F.P.CG. ,