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FOR OFFICE USE: / Permit No. ---------- APPLICATION FOR SANITATION PERMIT - - (Complete in 1 Year Date Issued Duplicate) Date issued __ _l •-�• ---------- This Permit Ex truct and install the work herein described. Applicationis hereby made to the San Joaquin ocal.Health DlNoc for a permit to conse - This application is made in compliance withCounty Ll_e-------------------- JOB ADDRESS AND LOC N----- - Phone-_ 6- ? f - © � �-= l` ................. Owners Name__________________ ;e—V-77- --------f - - ----------- Address --•--- Phone.- -� a 7 .� .moi:-•'r-�'--- - -- ----------------- -------- - Contractor's Name---------- Other ❑ Installation will serve: Residence Q'/'Apartment House El Commercial F] Trailer Court ❑ Motel ❑ Number of living units: ---/.. Number of bedrooms _ -" Number of baths "- - Lot size _-� - Private �6epth to Water Tabled ft. Water Supply: Public system ❑ .Community system ❑ ❑ Character Supply: soil to i depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [KClay.-Loam ❑ Clay ❑. Adore❑ Hardpan ❑ ❑ [ FHA/VA: Ye ❑ No [H— previous Application Made: (if yes,date.___------------ --1 No []- New Construction: Yes No TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or Cesspool permitted if public sewer is available within 200 feet.] earest well___- _ ___-__Distance from foundation_ --__�d-e�p-t-h--_-_._M_.--a-`t7enai, ---- -C�ap--a--c--i-t-y--_-_-,-�--7•--_-4_-r-_-- ------------ I Distce from nSe tic Tank: Size--------------------------- -- Liquid El No. of compartments------------------ l Disposal Field: Distance from nearest well--7 _-------- .Distance from foundat11 ion."" ---- --Distance to nearest lot liner-------------- Number of lines------- 1____ - . -"""___.__Length of each line--,J-0 E Width of trench__- W- -� Type of filter materia4___ __. �C/ ___Depth of filter material_____1 "---.--- dotal length________ __ ----------- j-;- I i /EOZ7 _.Distance to nearest lot line___-' .--- -;-_ - Distance to nearest well__�l�p-_.-_-___Distance fr foundation_-______ Seepage .it: _Size: Diameter---le' ------- ------ Number of pits_:-------,�---------Lining material S Distance from nearest well._____.-_.______Distance from foundation____...---__.-----Lining material__-_.._----------------------------- Cesspool: ----.Li uid Capacity----------------------------gals.U El Size: Diameter----- ----------------------------- Depth------------------------------ ------ -- -- - g Distance from nearest well----------- ----- - ------ ------- -- -- ------Distance from nearest building--------------------------------------- Privy: ------------------- ------- ------ ---- Privy: ------------------------=---- ❑ Distance to nearest lot line---------------------------- t Remodeling and/or.repairing (describe}:___-----� _________---------- --------------------------------------------------------------------------------------------------------------- -------------------------------------------- -----------• ---------------------------------------------------- ------------------------------------ ------------------------------------------ 4 I hereby cart ify that I e prepared this application and that the work will be done in accordance with San Joaquin Coun#y ordinances, State law in r as and regulations of the San Joaquin Local Health District. caner nd/or Contractor) --------------------------- (Signed)--------•--------------- - - J - (Title)----- - - ----------------- By: ---- -- -------- --- -- - -- -- -- By:: --- -- ---- -- --- - (Plot plan, showing size o at, location of s tem in rela#io0o-wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY DATE-----7'-------- ----------------- - APPLICATION ACCEPTED BY-- $ ------ ------- DATE------------------------------------------------------------ ---------------- BY REVIEWED ER----------------------------- ------------------------ ----------------------------------------•----------------------------------------.-- BUILDING PERMIT ISSUED--------------------------------------------------------- ----- ---- ----- ------------- --------------- -----•------------------------ ------ ---------- Alterations and/or recomme d ------ G1 -0.&;--- --------- °------------------------ ---------- ------------------------------ --- --- ---- ------------- - FINAL INSPECTION BY------; --------- -------- '-- -- - " ------ SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street � Lodi,California Manteca,California Tracy,California Stockton,California F.P.0 O.