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FOR OFFICE USE: ------------------------- ---------- --------------------- APPLICATION FOR SANITATION PERMIT Permit ---------------- -------------------- ------------------- ------------------------7------------- --- --------------- icate) Date Issued (Complete in Duplicate) ---------------- -_--------------------------- This Permit Expires 11 Year From,Date Issued Application Js hereby made to the Son Joaquin Local Health District f&�a,permit to construct and install the work herein described. This applic6tion is made in compliance with County Ordinance No. 549. JOB ADDRESS AND --------- ----- --- ------------------------- Owner's Name----------------_ ----- ------ Phone-----------•------------------------ Address------_--------------------- -------------0 /---------W------------------------------------------ ------------------- 71 ----`-----------------I-A -------- Phone._':A.�_6:J?.4- 2��.?------ Contractor's Name---------------- Installation will serve: Residence E] Apartment House 0 Commercial 'Trailer Court [] Mot I [] Other ❑ Number of living units. _-' Number of bedrooms --—---Number of baths --=- Lot size ------- ------------------- Water Supply: Public system E] Community system [_1 Private 2?"Depth-to Wafer Table -------- ff. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [] Clay Loam [ Clay 0 Adobe [] Hardpan F] Previous Application Made: (If yes,date---- ------7--------I No � New Construction: Yes 0 No � FHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within.200 feet.) `Distance from nearest we'll om ioundatio,/ 4p-----Material________----------------------------------------- Septic Tank: ---- Distance fr i ?- -- ----- CapacitV,77a9_43'_---- Fri� - No. of compartments---------- - --------------Size_,6�,f�te??---------Liquid depth__.` Field: Distance from nearest wellJo.a Distance from f'oundafion-/-�?!��?-"----,Disfance to nearest lot linex�. Number of lines_____--- ----------------------Length of each ----Width of trench. --------------------- W--*' - - -_ ' ------------------------ Type of material-__01 Depth of filter material-,?----____-___Total length----467,5�__� Seepage Pi.f: Distance to nearest well-----------------------Distance from foundation_________________--Distance to nearest lot line_-__________-_.-_ ❑ ine----------------- 171 Number of pits------------- ------Lining material------------------------Size: Diameter-----------------------Depth-------------- --------------- Cesspool: Distance from nearest well-----------------Distance from foundation_:_____-----------Lining material-___---__-_-___-_-__-_______________ ----- F1 Size- Diameter--------------------------------------Depth--------------1_------- -----------------------Liquid Capacity----------------- gals. - Privy: Distance from'neares't wO--------------------------------------- ---------Distance froffi-nearest building___________--_.-_____________.______-_-_. [) Distance uilding------------------------------------------ Distanceto nearest line-- ------------------------- ------------------------------------------------------------------------------------------------------------ or repairiinLq (descr ell —--------- Rengodeiinq and/ 'ibe' -------------------ge. ----------- ----- ---------------- ---------------- ---------------......I------4�'�_ -------f/ --0 ------------------------------------------------------------------------------------------------------------------------- ---------- --------------------- 1 --------------_----------- -------------------------- ----------:-------------------------------------------------------------I-------------------------------------------------------------------------------------------------------------- - --------------------- ------------ 1.here 6y.-certify that I have prepared this application' pnd that the work will be done in accordance with San Joaquin County ordinances, State laws, ander, es and regulations of the San Joaquin Local Health District. --------- -------- Contractor) ------- Qw and/or Contr c (Signed)--------------------- ------------------------------ ------------- .4- ?,- - ------------------------------------------ (Title) By:------------------- -------------6 ----------- .... . .............. ------r (Plot plan, showing size of lot, location of sysm in r e I a ti o'ii,.,.f 9 wells, buildings, etc., can be placed an reverse Side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------------- --------- ------------------------------------------------------------- DATE------------------------------------------------------------ REVIEWEDBY-----------I---------------------- ------ ------------ -- ----------------------------------------- -------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------- ----------------------------------------------------- -----------------=--------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------- ----------------------------- ---------------------------------------------------------------------------------------------------------------------- - ----------I------ -------------------------------------------------------- ------------------------ -------------------- ------------•----------- ------------------------------------------------------------------------- m ---------------------------------------------- --------------------- -------------------------- -------------------- -------------------------------------------------- ------- ------------------ --------------------- -------------- - -- -------------- ------ ---- ----------- --------------------- ------------------------ ------------ -------------------- ---------------------- - ----- --- --------------------- - FINAL INSPECTION BY:----- --------------------- ------------ ------------- Date....... ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street SiocktOnr California Lodi,California Manteca,California Tracy,California E5 4 REVI5F611 11,511 31*1 3-'63 F.P,Cll.