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FOR OFFICE USE: -------------------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...�t1 ------------------------ --------------- i --------------------------------------------------- ---- . (Complete in Duplicate) __.-:._ This Permit Expires i Year From Date Issued Date Issued 1�=� - t Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 544. �7d JOB ADDRESS AND LOCATION------ -----'Y`�f�, 'L.(J: r .P�rc �. �.... Owner's Name--- r .r.: /�'t f - ----- V -.- -_._"Phone._....__... Address. t ' ------- --------------------------- -----------------------•--------------------------- Contractor's Name = • f- ----•------------------ Phone................ f Installation will serve: Residence ❑ IIpa tment House ❑ Commercial ❑ Trailer Court ❑- Motel ❑ Other I2� p�f „Number of living units: ---L___ Number of bedrooms __ Number of baths ---)... Lot size .3-01--- --- ------- -------------------------- Watet Supply: Publicsystem ❑. Community system ❑ PrivateDepth to Water Table _M ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay E] Adobe Hardpan Previous Application Made: (If yes,date____________________) No New Construction: Yes No E] FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS.— EC FICATIONSc ,,. (No septic.•tank orcesspoolpermitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---_ _Distance fro foun tiont _ u - p rry ",lg 4QiMa ria) -------- - -------------------- ---- ------ No. -----No. of compartments_----___-- -------SizeSX'1 '_X,_.___Liquid depth_... :-----------__Capacity_P__.1;2 _ Disposal Field: Distance from nearest well------ 1.` __.Distance from foundation__ 7 _Distance to nearest lot line_._J'r__--__- , , Number of lines:.... ------ ength of each line_,�_P_._�.I.�__.Width of trench._..__ Ar_________._ �. YP � p g Type of filter material-_--a .__ e fh of filter material_______ __ _________TOtdl length Seepage Pit: Distance to nearest well-...-___--------------Distance from foundation-------------"-----Distance to nearest lot line----------------- . ❑ Number of pits--------------------Lining material----------------------Size: Diameter--------------------- Depth--------------------------------- \ Cesspool: Distance from nearest well-----------------_Distance from foundation--------------.---- Lining material__..__----------- ❑ `^Size: Diameter.------------------------------------Depth -- --------- ,Y ---------------------Liquid Capacity- -=- --.gals. -_.'.:^-• ------�--�---�--�..��- Privy: Distance from nearest well;. _- _ Distance .from nearest building ---- I ❑ Distance to nearest lot hne---------------------------------- ---------- -- -------------------- - Remodeling and/or repairing (describe)-----------------------------------------•-----------•-------•----------------------------------•-------------------•---•------ ------ -------------------------------------------------I---------------------------------------------I--------------- -----------••-------------- ----•------------------------------------------••------------- -- -------------------------------------- --------------------•- --------.---------------------------------------•---•--------------------------------------- --------------------------------------------- ---------=----------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I 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. ; nI \rl\ t (Signed-� y---- ---------------------------------------------------------------{Owner and/or Contractor) By:.... ----- -- -(Tit) --------------------•------------------------------------- (Plot plan, showingg sizeofJliSf, location of system in Fela`tion to wells;buildings;etc. `can be`placed'on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---------------=----- - ,r DATE - - - --------------------- REVIEWED BY--------------------------------------------- --------------------------------= j =f DATE- f /� BUILDING PERMIT ISSUED__.... --=------------------------------------------------------=-------------------------------- DATE--------•------------------- - . Alterations and/or recommendations:_--------- ------ -------------------------------------------------------------•-----------•-••---------------------------------------------------------------- t --------•----•---•--•----------•-------•---------•--------•- -----•----------------------------------- ---•- ------------------------------------------------------------------------------ F! -----•--------------------------------------------- ----------------------------------------------------------------------------------------------- ----------------------------------------------------- ------•--- ----- ------`- r V_._...__ ._. ------------------ D FINAL INSPECTION BY:. ' - / Date ✓- __ _.__._.._. _ -_----------------------------- i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. I 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocklon,California t Lodi,California Manteca,California Tracy,California w CS 9 REVISED B-5$ 3M 3•'83 F.P.0 D. ��w , )