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FOR OFFICE USE: ------ APPLICATION FOR SANITATION PERMIT Permit No. ........... ---- ------------ ---------------- ------ (Complete in Duplicate) �1 - -------- ---- ..----.-. - ..-. This Permit Expires 1 Year From Date Issued Date Issued - -------------------- I Application is hereby made to the San Joaquin Local Health District for a permit to con struct_and-insbll the,work herein described. This application is made in compliance with County Ordinance No. 549. ' ;2' -$,°.Y✓ �-fir JOB ADDRESS AND LOCATION.. -------------------- - _ m " Owner's Name--------��---- ..... _.-. _,cl---- - - g� --- Address - Phone - ------ - t Address------------ �'' f __..._7 '--------- -•---��+..J_. ------------------------ --_ ----------------_.--.--..... -----------.-------- '��------- ------I——--------- -------------------- Phone-- •" �� Contractor s Name-__-. / Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms.- Number of baths __2--Lof size ----- - f Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. 4E;% Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: {if yes,date--------------_---.I No ❑ New Construction: Yes E�` No ❑ FHA/VA: Yes ❑ No �yaP TYPE OF, INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool Qermitted'ifpublicblic sewer'rii, aavailable within 200 Septic Tank: Distance from nearest well-/ -Distaancefrom foundation la_!� l ___Materia -- '-____-_-_ 1 No. of compartments-._____-�_________-_Size----tjl_6 -` _-_------.Liquid depth----------Y-----------Capacity....Zo?0 Disposal Field: Distance of {ineseares�lX��--LDentgth of from line�o%��_-'�_-.Widthcofttrench est-I�line_____�� from ------ ------ Type of filter material__ // Depth of filter materia!___re �% �fotal length-.-- �- --- ----.- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_- 1----------., ❑ Number of pits----------*-----------Lining material-----------------------Size: Diameter----•---- ............Depth_------------------_------------ Cesspool: Distance from nearest well-----------------Distance from foundation-----.------------- Lining material---.--.-----------------:---_.-------. ❑ Size: Diameter ---------- ---Depth----------------------------------------------------Liquid Capacity----------------------------gals. kl Distance from nearest building Privy: Distance from nearest well -- ----------------------------------- 9 -------------------------------------- ❑ ' Distance to nearest lot line---- -----------------------------------------•------------------------------------------------------- -------- ---- - - Ir Remodeling and/or repairing (describe)----------------------•----------- ----------------------------- -----•------•-•---•--------•--------------------------•------------------------- ------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- r -------------------------------------------------------------------•--•------------------------------------------------------------------------------------------------------------------•-----------------------=------------ ------------ - - -- ---- ..-------------------—---p------------------pp-----------------------------------------------:-------------------.-----------—----------•.--- - --------------------- I hereby certifythat I have prepared this application and that the work will be done to accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. {Signed)--4, , - 1 {Owner and/or Contractor) -Pla Ian, showing size of lot, location of system : relat n to wells, buildings, etc. ITi#le)--"- - " - — rt� __a- _ -Zion ( p g y g , can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -------- ----- DATE-_-__._ _--=I�-�1 -- - -- ------ ------ ----------------------- ---- ------------------ - REVIEWEDBY----------------------------- ------- ------ ------ -- ------------------------------------------- DATE----------------------------------------- BUILDING PERMIT ISSUED-------------------------- j --------------•----------------------- DATE--------- --------------------------- �. Alterations and/or recommendations:.-..- - �1/,Q ` `L !!x� ---------------•-----_---------------------------- -- --- ------- - ------ -----------------------------------------------•---------------------=---------------------- ----------------- ---- �3 7 FINAL INSPECTION /_ Date.------ ------- - -----.---.' A AQUIN LOCAL HEALTH DISTRICT 1601 E.Haze ton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Lodi,California Manteca,California Trac Stockton,California Y,California r w F.P.0 O.