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4tfi.( APPLICATION FOR SANITATION PERMIT Permit No. y� �` � ; �, {Complete in Duplicate) II Date Issued _______._----'--______ Application is hereby made to the San Joaquin Local Health District for a permit fib construct and install the work herein described. This application is made in compliance with County Ord-inance'No.•549. JOB ADDRESS AND LOCATION_ __ ----------------- Owner's Name----- -- � i:_-� - = Phone . -- Address ----- --------X + t ` ------- ----- Contractor's Name - -;-= ------------------------ Pho-ne----------------------------------- Installation will serve: Residence U4�'Apartment House_ ❑ Commercial ❑ Trailer Court ❑ Motel ❑ 9Other ❑ Number of livingJ Number of baths units: _�--- Number of bedrooms /_� Lot size - Water Supply: Public system ❑" Coinmuriit s stem Privates y y V❑ )!Depth to Water Table Character of soil.to a depth of 3 feet: . Sand ❑ Gravel [j Sandy'Loa'm ❑ Clay Loam RClay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ( ',New Construction: Yes R"No ❑ FHA/VA: Yes 2�, No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: T ' isa� i (No sepfic.tank or'cesspool permitted if public sewer is available within 200 feet.) w le.— . — =fir,; - s Septic Tank: Distance from nearest wel -_ 0------Distance from foundation---le-_______-Material-__ -" _ . ----------- No. �3 of compartments__________________kSize_ _ _! ___ _-_Liquid depth___ ___`Capacity--e...11741 t' I Disposal Field: Distance from nearest well-4Z_ . ..Distance from foundation___ -"".Distance to nearest lot line—Aa-11- Number of lines------Z-------------- en th of each line `` '� --------•--\ - --- - 9 -r---�--------=------Wid#h of trench-- y Type of filter material_./4_ epth of filter material-_: y _4!.....Total length-----, r .e 9 --� ter.. — F b. q I ... - _ :__._..Dist �!e to nearest lot line__ __ Seepage Pit: Distance to nearest well____ 1� Distance frpm un tion__ Number of pits.___-_-/----------'Lining materialf ize: Diameter,,? Depth--.__..;Z.49:---_•___ -- 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_---._------ ---------------------------------------------. �.,. ----------- Remodelin and or repairing describe :____-_.._: j ----- ••-.---- ----------------------------------=--------------': -------------------- ------------------------------------------:--------:---- _.__.... --------------- - ---------------------------- --------•---- ------------- ----•--------•-----------••-----------------------------------•-----•--------•----------------- -------------------------------------- ----------------------------------------------------- ----------------------•-------------------------------------------"----------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------'----------- I hereby certify that 1-have prepared this application and that the work will be done in accordance with San Joaquin County �I _ ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. {Si ned a - 9 ) ' r---------- ��Contractor) By:_---------------------------------- - ------- - -------------------- ------------------------(rtle) (Plot plan, showing size of lot, ation of system#in relation to wells, buildings, etc., can be placed on revers ide). FOR DEPARTMENT USE ONLY I ' APPLICATION ACCEPTED'BY-------- ------;--,-----•------------------------------------ DATE--------- r REVIEWED BY-- . : �Z� L J --- DATE---------- ------------------ BUILDING PERMIT ISSUED ----------------- --------------- - DATE --------------- ---"rations and/or recommendations----------------------- - - ---------------------------` -------------------------- - -------- ---------------------------------•---•-------•-------------------------------------------------- -------------------------------------------- ------- ----------•--------: ------ ti ----------------- • - ------------------------------------- ---------- ---------- `:TIONBY:.- Date. A SAN ,JOA QWNLOCAL`HEALTH DISTRICT ierican Street 300 West W Street • ` 1 132 Sycamore Street •814 North "C" Street California -.VA \�Z, w Lodi,i California,-,4 Manteca, California�� Tracy, California i µ Revisea 1-57 F.P,CO. -�