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FOR OFFICE USE: --- - ---- - -- ------------------- �i _---------_-----________________________-__--__._ ----- APPLICATION FOR SANITATION PERMIT Permit No. .�.Q.-_.2a.. --------------------------------------------------------- (Complete in Duplicate) ------------------ 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 a d install the work herein described. This applicatiolitis_made..in_compliance with County Ordinance No. 549. r JOB ADDRESS AND LOCATION -------------- __/1_ ;-"`�"'-ct = C?.S3_- `T j Owner's Name - - ------ Ph ••--•------------------------------- Address �'- --------- --- ----------- . ......_ ---------•---•--- Contractor's Name------r .- -- � .`1� •_. � one. - Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J___- Number of bedrooms _ -___'Number of baths __.2-_ Lot size _________ __ _______ ___ ________________________________ Water Supply: Publics stem t y ❑ Community system ❑ Private, Depth to Water Table��"�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam M Clay Loam Clay ❑ Adobe ❑ Hardpan* Previous Application Made: (If yes,date___------_------ ---1 No 2� New Construction: Yes J� No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - _ (Na-septic tank or cesspool p&mitfed if public sewer is availabl within 200 feet.) Septic Tank: Distance from nearest well-- �� -- Distance from founclation__. 0'-------Material-_ ; No. of compartments---- ------------ ----Size-_�_:f__d-_f___$ -----...Liquid depth-------/----------------Capacity_c? ---------- k DFsp al Field: Distance from nearest well.�a -__..-Distance from foundation ______.Distance to nearest lot linesf.f___ Number of lines____r ---------------------------Length of each line-----f ----------------Width of trench---- ---------------------- Type _________._____-__: Te of filter materia[ _______Total length____ -67J:_r____________________� r yp _- _Depth of filter matenal_____ _ _' ,tl Seepage Pit; Distance to nearest well---------------------- 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----------------------------------------------------Liquid Capacity ---------------------------gals I Privy: Distance from nearest well-----------------------------------------------__Distance from nearest building--------------------------------------- ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------- �~ �� � = lI Remodeling and/or repairing (describe)----------------------- -------------------------------= , ----------------•-••-------------•-------------------------------------• --------------------------------------------------------------------------------------------------------------------------------------- __________________________________________________________________________---___________________________________________________________________________________________________________________________________________j �. ____________________________________.__----------------------.---------------------------------------------------------------------------------------------------------------------------.___..____-.-____-____-__________--- k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count•,._-rC ordinances, State laws, and rales and regulations of the San Joaquin Local Health District. (Signed)-- _____________ Owner and or Contractor _ ._ . . __ -- . _ - $Y••--------- - - ----------••- ---------- - ------ ------------ -------°------------ r----�-- 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 APPLICATION ACCEPTED BY . - = DATI= -�' ' -------- ----------------- REVIEWEDBY----------------------------------- --------- ------------------------------------------------------------------------------ DATE----- ------- -----------------------•-------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------- ------ DATE------------------------------ Alterations and/or recommendations:-----------------------=---------------------- -------------------•------------------- ---------------------------------------- ------------------------------------------------------- --------------------------------------------•- --------------•---•---•----------•------•-------------• •------------.------ -------------- ------------------------------------------------------------------------------------------------------------------------- ------------------------------------ FINAL INSPECTION $Y:__ � :r / --------------------- Date.--- -- ---��-5------- --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stackton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-59 31`4 3-'63 F.P.CO. , N