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FOR OFFICE USE: - -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No, ................ ----------------------- ---- -------- (Complete in Duplicate) D 4.3 ---------------------- ----- - This Permit Expires 1 Year From-Date Issued Date issued ___....__ _ _ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descrbed. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND CATION---10-0W-7-------- , 1 --------------------------------------- ----------------------------------------------------------- Owner's Name-... /U ,.1YY-�- ----------- ------------------------------------- Phone----------------------------------- - -- --- -- ._ _ . --------•-----------------------------------••-•----------------------------------------------- Contractor's Name---- �d. .-----------•--------------------------------------••-•--------•----------------------. Phone-----•-------.----------••--------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --1-.- Number of bedroom _Number of baths e__ Lot size w__. ,lr --------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table6_Jft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand oam ❑ Clay Loam�Wo y [IAdobe,�ardpan E]Previous Application Made: (If yes,date_..___._---___..._I No New Construction: Yes ❑ FHA/VA: Yes ❑�No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well------ Distance from foundation_-/d---.____-.Maf rial---L�C% �_1 .��_________________ Lam' No. of compartments----------'Zr_---Size----,,$`sem -- /f7_--Liquid depth__'f�.1 ,----------CapacitY---_ J----- Disposal Field: Distance from nearest weii__�_-Distance from foundation---Id .....Distance to nearest lot line__.S�_�____ Number of lines_________________________Length of each line__r_ - 7.J--______.Width of trench_.. _ -. gve_ g �� ,� Type of filter material__)?_0cz1------Depth of filter materiaLItl 41--------Total length__•/__ ____________ Seepag it: Distance to nearest well_��_.____--Distance from foundation___�_U_t..___.D�ance to nearest lot li e_�__-_------.. G Number of its.-�"'______________Linin material , __ Size: Diameter_ f p�.. 9 �--- ,.�----- ---------Depth- - -- ----;--- Cesspool: Distance from nearest well-----------------Distance from foundation----_._°-_.__---_Lining material-_------------------------------------ ❑ Size: Diameter------------- - ----------------- ----Depth------'-------------------------------------r' Liquid Capacity----------------------------gals, Privy: Distance from nearest well--------------_--------------------------.----_Distance from nearest building_..____-__._.---_-_________________----- r, ❑ Distance to nearest lot line_____________________________________ Yu/ I�,�/...----- -----•-------------------••---------------------------------- Remodeling and/or repairing (describe):............��_ ,Si l . M --------------------------------------------- --------------•-------------------------•-----------..----------------------------------------------- �s ------------------------ ---------------------------------..---------------------------------------------------------------------------------------------------------------------------------- ---------- -- I hereby certify ve prepared pplication and that +he work will be done in accordance with San Joaquin County ordinances, State laws an I s and re la ' n of the San Joaquin Local Health District. -------- ---------------------- ---------------------------------------------- (Signed]___________________ _____ ____ __.(Owner and/or Contractor) By:---------------------`------- - - ------ -- ------------------------.-----------{Title}---- � ............. (Plot plan, showing size I , location of system in relation to ells, buildings, etc., can .be placed on reverse side F R DEPART NT U E ONLY APPLICATION ACCEPTED - ------ -- -- --- -- -- DATE----- -- REVIEWED BY---- --------------------------- --------- -- ----- ---------------- --- DATE BUILDING PERMIT ISSUED----------------------- -- -- ------ ----- /----- DAT ----------- Alterations and/or recommendations:-------- ---� 3` ----- --�---- -- --- ------ --------------- -------------------------------------- -•----------------------- ---------------------------------------------- -- --- ----------------------------------------------------------- ---------------------------------------------------------------------------- ---------•--------------------- ----------------------- ----------------------------- --------------------I---------------- --•-------------------------------------------------------------- -------- ----•----------------------------------------------------------------------------------------- -------------------------------------------------------------------------- --------------------------------- ---------- ------------- ----•----------- ----------------I--- -------------- ----•--------------------------------------------------------- = ------------------- FINAL INSPECTION BY---- ---- --- - ---- -- ---- - --- ---- -- ---- Date_. . AN JOA IN LOCAL EALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street d Statklon,California a Lodi,California Mantecar California Tracy,California ` ES 9 REVISED 6-59 3M 3-'63 F.P.126.