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r` FOR OFFICE USE: 3 i- -4* ------------------- �C APPLICATION FOR SANITATION PERMIT Permit No. ___,I TD. ..... ------------------------- -- /�`-Y�----- -------------------------------------------r--_4 (Complete in Duplicate) ' Date Issued ______________________________ ____-----_.-------------- This Permit Expires I 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 Ordinance . 542. JOB ADDRESS 4 L CATION--- ZZ g----C-------- t Owner's Name ! --------------------------- ---------------- - - ----------- Phone Address-----2:�~. Lr ------ Contractor's Name--------- ------ --_C__3------------------------- ----- -------- Phone----------------------------------- Installation will serve: Residence Er—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._____ Number of bedrooms __ •- --------------fOa _ Number of baths _�----- Lot size --------------------- ------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _6/_0 ft. Character of soil to a•depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [ hardpan ❑ Previous Application Made: (If yes,date--------------------) No [ New Construction-. Yes 99--150- ❑ FHA/VA: YeEr❑ No f�-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r ``�� Septic Tank: Distance from nearest well-_______-______Distance from foundation,4d--- -----------Materialr_!_'4 '°_ [� No. of compartments-..�------------------Size------ Liquid depth------I?--.`------------Capacity_-- --DU_�_____-- Disposal Field: Distance from nearest well----F_ --------Distance from foundation---j ------------Distance to nearest lot line__ ______ Number of lines----1_-____ -------Length of each line----2a= f �_" ---------------Width of trench..> _ ..______________- �J Type of filter material__ O5:�_________Depth of filter material--- length length __-______________________.____ rt Seepage Pit: Distance to nearest-well___-�___._._._._Distante oj �•m foundation---�iO___.._____Distance to nearest lot li�rS_ ..... S 4�� Number of pits_.�,t._,z------: ..Lining materia'I-_-_ 4v t. _-..Size: Diameter----J� _ . __ __.____Depth__ Z,)r ---------- Cesspool: Distance.from nearest-we}----------------- from foundation---------.----------Lining material__..--------------------_-_-_-____-_. Size: Diameter--------------------------------------Depth------------------------- ------------------Liquid Capacity -----gals. Privy: Distance from nearest well--------------------------- from nearest building______________________________________. ❑ Distance to nearest lot line------------------------------------- ----- ------------------------------------------------------------------------------------------------- �} Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------•-------------------------------------- L" -_---•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------•--•--------------•---------------------...... ---•-----------------------------•--•------------------------•------•------------------------------ ------------------------------------ ------- ---------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ -- I hereby certify that I have prepare is ap Iicafion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and atio of the San Joaquin Local Health District. (Signed) ___________________________________ Owner and/or Contractor BY=--------------------- -------------------------------------------------- ------(Title)------------------------- -------------------------------------- (Plot plan, showing size of lot, location of system in elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY-------- - ----------------------------------------------------------- DATE---Z=- ;1 ----------------------------- REVIEWEDBY----------------------------------- ----------- - ----- - ----------------------------------------------•-----•-------------_ DATE-_-------------------------------------------------------- BUILDING ATE_ •-------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------—-------------------------------------- DATE----------------------------------------------------------__ Aiterati ns and/or reco p da+ions•________________..._____.___.._ --------- .. f L• '�-- . :r -------------------------- lie FINAL INSPECTION BY:---------- {�!€'- ' ------------------------ Date `1 - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Mazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Y,California Lodi,California Manteca,California Tracy,Stockton,California � ES 9 REVISED S-59 31A 3-'63 F.P.CC.