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• FOR OFFL E USE: 'Q APPLICATION FOR SANITATION PERMIT Permit No. ........................ -------� :__.4 �-- --- --_-- (Complete in Duplicate) Date Issued h .(a3 -{ __.___ 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 clescried. This application is made in compliance with County O dinanc h No 544. I� JOB ADDRESS.-`AND LOC4TION _ --------- ------- - Owner's Name_ 1/l- - - ®® Phone_.. :.. klrC ------------ - ---------------------------- Address---------------�r-'-''�- ----------- _ ---------..,.----------------- - Contractor's Nalme-_____-___ _ Phone --------------------------- 1[ Installation will serve: Residence R�partment House C1 Commercial ❑ Trailer Court ❑ Mofiel E] Other [I"� --- ------- Number of living units: __j.____ Number of bedrooms -_ __ Number of baths -(-____Lot size _ �-X�J------------ Water Supply: ::Public:system El Community system Private ❑ Depth to Water Table ______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [-] Sandy loam El Clay Loam C3 Clay ❑ Adobe ---Hardpan C] ! ❑ No FHA/VA: Yes No Previous Application Made: {If yes,dote_________________ __1 No.�New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept Tank' `"g Distance from nearest well_________________Distance from foundation_______:____---__._.Material_______-_-__:._.___.__- ________.__...__"_-.. ✓ No. of compartments Size ------------ epth----- -------Liquid dCapacity DisposA Field: Distance from nearest well_________________Distance from foundation-------------------.Distance to nearest lot line---.------------- ❑� '�Q Number of lines---"------------------------------Length of each Zine Width of trench filter material length__""--,__________:__..-------,-�------- .Type.of filter material____-"-----------------Depth of 6 Seepa it: Distance to nearest well,/• :___----___Distance from foundation ._ L#.....----- tante to nearest lot line_3.____-.__.__ Number of pits" ---f______________Lining material___] Diameter__. Depth �� . �. Cesspool:" Distance from nearest well-________________Distance from foundation_____-"-__-_.______.Lining material___._________---________________-__. ❑ - ---Depth------------------------- -----------Liquid Capacity gals. Size: Diameter------ - ----------- -------- -- ------------ Privy: Distance from nearest well-------------------------------------------------Distance from.nearest building------------------------------------- ❑ i Distance to nearest lot line-------------------------------- ---------------------------------------------------------------•--- ------------------- Remodeling an repairing (describe);------------ ---------------•----------------- -------------------•----------••---•-------------- �i 4 i. - ________________________________________________ _________________________________ ______ ----_------------------------------------------------------------------------ __________________________ - -----`c------- - ------------------------------------------------------------- I hereby certify that I have prepa is application and tat the work will he d net+n accordance with San ----------------------- Joaquin County ordinances, State laws,, and rules and regulations o the-San quip Local He IT � ---------------------------(Owner and/or Contractor) (Signed) T (Plot plan, showing size of lot, locate n o e tion.to.wells, buildings, •etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY „ DATE _�_ `_E __. APPLICATION ACCEPTED BY------------ REVIEWED BY.-----------=--------------- --- --- ------=----------- DATE_ -i- ----------------- = BUILDING PERMIT ISSUED----------------------------------------- = = DATE Alteration and/or recomm d do ---•--- ---=- _ r---- r ----- II ------ ---- =------------------------- --._.. c f : �` - � ------------ - ------ ------- ------------------ ------ ---------------------------------------------------------- ----- 0 FINAL INSPECTION BY:----------`--�---. ----------------------- -- Date-----t --� - ------ �' ------------------ --------------------- II SAN JOAQUIN LOCAL HEALTH DISTRICT i 24 Sycamore Street 205 West 9th Street 1G01�E.Hazelton Ave.Ara. 300 West Oak Street Lodi,California Manteca,California Tracy,California Stockton,California CS 9 RrvISEO 8-59 3M 3••67 F.I.X13. rl