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FOR OFFICE USE: =---------------------- ----4 ` o APPLICATION, FOR SANITATION PERMIT Permit No.�.___�..... ------- -------------------------------------- /.�_ _.-----_________________________________._. �--- {Comple+e'"in Duplicate] Date Issued ---------------____ ------------•---------_5!4?--- This Permit Expires 1 Year'From Date Issued 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 Ordina ce No. 549. JOB ADDRESS A .LOCATION - �[.� ----•---- t — --------- -1 -- Owner's Name------ - -------------------•-------- --------- ---------- UA ------._. Phone__Az""3E1�T'!� l Address �i.1... 4- --- --- - - ----------------------- (r} t ne..- (� Contrac#or's Na!m -� --- �- ---�` - - - - � ---- -- - - - - - •- I Installation will serve: Residence Apartme House ❑ ommercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ___ ---_ Number of bedrooms___ Number of baths _Z Lot size /--- ---- ------ ------ j Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table �ft. + Character of soil to a depth of 3 feet: .Sand E] Gravel ❑ Sandy Loam E] Clay�L�am E] Clay ❑ Adobe�rcdpan (IPrevious Application Made: (If yes,d __ate.__ _.-- .._-----) No E] New Construction: Yes+❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S i Distance from nearest well________________Distance from foundation---_.____________.Material-_-_--.-__�' J, `*y No. of compartments-------------------- ----Size----- ----------Liquid Liquid depth---------- '------------Capacity---------------------- x ----`- os d Distance from nearest well_RU1LJL..>..._.Distance' from foundation___1_0_0 to nearest lot line___ Number of imes___._I---- ___ ----- _ .____Length of each line.._ __ -.Q_ _ _ _____.Width of trench .24Z _._� �/� ------------ Type of filter materia .... _ __.Depth of filter materia____.1.5__-______._Total length----------------`7` ---__--__________._ S a e Distance to nearest well_ Old- -------Distance from foundation__.........Distance to nearest lot knee.Is-------- Number of pits.-I---------- ._..._Lining material_ --------- . Size: Diameter__��°r..__-Depth---- ____-------------- `\ . Cesspool: Distance from nearest well__._____._.___._Distance fro oundation------------------..Lining material____________________________________ v ❑ Size: Diameter-------------------------- -----------Depth----------- ---------------------------------------Liquid Capacity-- ------------------------gals. P Privy: Distance from nearest well-----------------------------------_-----------__Distance from nearest building-------------- --------------- -----.____. ❑ Distance to nearest lot line------------------- -------------------------------------------------------------------------------------------------------------- - Remodeling and/or-----------r--e----p----a-I--i--ring (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 Ian Joaquin Local Health Distri }, I `� `-- ` _IvAlcr Contractor) (Signed -----�, - Zwwo e By:----- •--- ---------------------------•---•--•-- ----------------------- - ---------------�----- ---- --------------{Title)-------------------------------------------- (Plot - - --------- -------------------- ------ --- (Plot plan, showing size of lot, location of system in ation to wells, build gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------- ------------------------------------------------------- DATE------ ----------------------------------------------------- REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------- - ----------------------------------------------------------------------- --- ---------------------------- DATE------------------------------------------------------------- Alterati ns and/or recommendation s: -`_----------- -----------•----------------------------------------------------------------------------------- ----------------U � F FINAL INSPECTION BY:------- ---- ------------------ R _ Date.- ------- ---------- - ---------- SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E.Hat:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocklon,California Lodi, California Manteca,California Tracy,California I F.P.CO. 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