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` FOR OFFICE USE: �------------------ APPLICATION FOR__SANITATION PERMIT Permit No. ..�� .. --- ----------------------------- {Complete in Duplicate) __,_ 3 Date Issued .... ------------------- --------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the SanFJoaquin Local Health District for a permit to cohstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOC ATION__o___ ___ ___ ------ ' �__..... .,.------- Owner's Name -- � ----------------- Address------- -------------`j-------- --•-----------•------------••-•----------------------------------------I----------------------------------_-_-, Contractor`s Name----- --------------------- - ----•---------------------- •----- ------------------------------------------------------------------------- Phone..------------------------------ Installation -----------`--. --- Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ , Number of living units: -_- Number of bedrooms _ Number of baths ____ Lot size ___��__ X ----------------------------------------- Water Supply: Public.system 0---community system ❑ Private ❑ Depth to Water Table _.------ .t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam � .Clay ❑ Adobe ❑ Hardpan El Previous Application Made: (If yes date____________________) No ❑/flew Construction: Yes El No D--FHA/VA: Yes ❑ No ❑ ~� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.). -Ai** r,.. Septic Tan Distance from nearest well----------------- from foundation----------_---------Material------- ---------------------------------------- No. ____.__,___--_.--.-__.__,_ " ❑ No. o 'compartments--------------------------Size-----------------------••-- --•Liquid del? --------------------------Capacity------ ---- -- Disposal Field:- Distance from nearest well_'T` I3is+ance from foundation___._ -____.Distance to nearest lot line.-_.:sr_____ O ❑g�� '��""�'Number of lines__ -----------Length of each line-------- - � � .t'.4- -----.Width of trench--------�-------------------•-- Type of filter material.____XG� �__ epth of filter material__,____f l�__Total length._______ _fes______________________ 0 tj Seepage Pit: Distance to nearest well-`` ______[ Lance/from foundation__.__l' __..Di�tanc�tQ nearest lot linef__-�__..__.__ Number of pits______:___________Lining material-,+ -S__tL�..Size: Diameter_�3,_-V___..___Depth__________ _________._____.._ I Cesspool: Distance from nearest we}l-___-__----------Distance from'foundation_-_--------------Lining material-------------------------------------- El Size: Diameter------------------ ------ Depth---------=-------;----------------------------------Liquid Capacity----------------------------gals. Priv Distance.from.nearest well_________________ I Y� --------------------x- -----= -Distance from nearest building------------------------- ------... ❑ Distance fo nearest lot line - ------------------ -------------------------------------------------------------- I Remodeling „� g and/or repairing (describe= - '--------- --------- -----'---------------- ------------- ----------------- __, -------------------- --------------------------------------- --------------------------=-------------------- ----------------------------------- ---------------------------------- ---- ---------------- '- = ----------------------------------------------------------------------------------------------------------------------------- I hereby certify that 1'.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. �S (Signed)--x---- � _ ------------------------------------------------------------------------(Owner and/or Contracfor] ` a ___(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 f� APPLICATION ACCEPTED BY-----------------�----- ._ .___. ---------------------------------- DATE__ �7 /---- -- ----- ----------- REVIEWED BY----------------------------------- -------- - -------- - ------ -------- ------------ ------------ " --------- DATE------ - BUILDING PERMIT ISSUED------_------------------- DATE ------ ------------------------------ __ f _______.__ --_12L-___�-C ----- Alterations and/or recommendations____________--------------------- ----------------------- ear r �r # �+ P] X. 2 ``.G —u�t_ cry—f` iR r�Y�c 1, 72� -----G��---- -------------- -- ------------- ......---7---- --- ---------- --------- •, -_ �--� FINAL INSP TION BY:.... - --- rJAN L ,> Date-------- ' ----------- ------------------ OAQUIN'LOCAL HEALTH DISTRICT rt 1601 E.Ha:ellon Ave:' 300 West Oak S►reet a *,, 124 Sycamore Street 205 West 9th Street Stocklon,California Lodi,California Manteca,California Tracy,California ES 9 REVISCO 8.59 3M 3-'63 P.P.pp.