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FOR OFFICE USE: =i --------------- APPLICATION FOR SANITATION PERMIT Permit No. .--.•------------------- ...---- -------------------------- ---------- --------- (Complete-in Duplicate) T I'll� ........................ ----.-----.-- --------------- This Permit Expires 1 Year From Date Issued Date issued _;? ______'__-- Application is hereby made to the San Joaquin Local Health District for a permit t4construd and install he work herein described. This application is made in compliance with County finance No. 549, JOB ADDRESS A LOCATION I.--- i - ----- '` --------- ----- --------- --- ------------------------------------------------ Owner's Name__-�Q�h-2�, -� �•---�.. Phone------------------------------------ !- -------------- ---- -----t------------------ -- Address __• ----- --------- - ------ ------------ ----------- ---••--------------- -- ...-•------- -- -- --- - Contractor's Name------ -_.- •-- -- PhoneQ � ----- ---- ---Lmercil Installation will serve: Residence., partm nt House ❑ ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -" ,. Number of bedrooms ;L W_ _ `�g r --- Number of baths-------- of size --- - --- ------ ------�-1-11----��--------•------- Water-Supply: Public system [ICommunity system E] Private A...<110to Water Table Wft � Character of soil to a depthofSand,] ',Gravel ❑ Sandy Loam ❑_Clay Loam ❑ Clay ❑ Adobe iardpan ❑ Previous Application Made., {i>f..yes,date_-_T__-..______. ] No'❑ 'New Construction: Yes ❑ No FICA/VA: Yes ❑ No ❑` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1P . Septic Tank: Distance from nearest well-9-19.__...__Distance from fou c of on___ ___-___-Materi`f__________________________ ___.___._...____. �� No. of cam artmen#s.. _..: _ .Size- .- 4 X� Li uid de th__�7Z_ _ Ca pacify_ A� 1, Disposal Field: Distance from nearest well.,' --.V Distance from foundation''�o "--._.-.-.Distance to nearest lot line.__-----. Number of line___t-1 ___ ______ Length of each €ine�Q r �_�__?F.___.... /idth of trench___Z. `!_____________ -- Type of filter materia ... ...----- ---Depth of filter material___C_ `- -___ -_Total length--/c�!_ 01__---_._--_ ._Seepage Pit: Distance to nearest w __ _______ ______Distance from foundation---.----- -_-_--..Distance to nearest lot line.____..._____..._ ❑ Number of pits... ------------- ---Lining material---------------------- Size: Diameter-----------_0- ....Depth________-------------_.------ Cesspool: Distance from nearest well ----------------Distance from foundation------------.---- ..Lining material--.-...____.------ -------- 171 Size: Diameter- -- --------- - --- -------- -------Depth------ ----- ---------------- --- ------Liquid 'Capacity- --------------------- ----gals. r1 Privy: Distance from fnearest well...... ..........................................Distance from nearest building_____-__.--------_-_---.---------.-------. ❑ I� tDistante to nearest lot line ---- ----- - ------------------------------------------------------------------------------------------------------- Redelincj Ind, 'r repa'ring I esc ribey ,_ .. - ---- ---- -- -.___-- i-- ----___-- 4'�_- - - --• - --- > ,.__ _ t - ------------------ s , I here y certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a la and rules and regulation of the Joaquin Local Health District. I (Signed) `k�.. cy --------- - _: >_ •P /or Contractorl By: ------- �/ 1.Q` - (Title) - (Plot plan, showing size of lot, location of system in relation tells, buildin , etc., can be placed-on reverse side). t n ,. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = DATE = /7------------------------------ REVIEWEDBY--------------------------- ---- ---- -------------------------------- DATE----------- ------------------------------------------------ BUILDING PERMIT ISSUED---------- -- ----------- -- `------. --------------------- ----- - --- --------- - DTE------------------ ---------------- --------- ----- Alterations and/or recommendations:.......S� .; . -- - -----------------------------------------...._ � •*- 0 -- ------------ -- -------------------------- ----------------------------- -------------------------------------------•--------------------- ----- ---------------•--------------- ---- -----------------•------------------- ------------- --------------------- -------------------- ----------------- - -------------------------------------------- ---------------- ------------------------------------ --- --------------------------- 1 ..................... ---- --------- ----------------------------- --- -------------------------------------------------------------------------- ------------------- - ---------------------- ---------------------- FINAL INSPECTION BY. ..... '------- ------------------ Date--- -� ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1607 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Slocktan,California Lodi California Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press