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FOR OFFICE USE: _3r_1 & v, t --? c7 _ --�----------:------------ _ .. „----,--_---, APPLICATION FOR SANITATION PERMIT Permit No. ------ -- ---------------------- ----------------------- (Complete in Duplicate) ___________________________________ This Permit Expires I Year From Date Issued 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 No. 549. O ?-7 - /'7D --ox 477 Z�AC_ JOB ADDRESS AND LOCATION..--_ L�lL_. e, tom_-A r - ----- `' '� Owner's Name �sr t ...----------- --------------------------------------------------------------------- --- Phone------------------------------- `� r Address------------_- 6i--------- •--• •----- '------------ --------- Contractor's Name----- -< ....__ �c� —------ _ - Phone__... `.' Installation,will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms 3__ Number of baths . Lot size `___� e�)_____________________ Water Supply: Public:system ❑ Community system ❑ Private [W Depth to Water Table X70_-'iT Character hof soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay N Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-__-___--__- ----) No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No;N TYPE OF INSTALLATION AND SPECIFICATIONS: f -- ( P P P P ) No septic tank or cesspool ermined if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_=�_(5_-_------Distance from foundation_---__a_____._._Material__ �__�___1R1�' '�___________- t No. of com artments_-__ Size_____ p �-------------- �� ---Liquid depth------"-�------------Capacity---/Z00__ -_. •J Disposal Field: Distance from nearest well- 5,6---------Distance from foundation___ _ 1L1________-__Distance to nearest lot IinA� ___-____- Number of lines___.___________-_-_______Length of each 1ine__��_r/__�__,Z_ -_-__ Width of trench_-.-__ �+1___________________ Type of filter material-_ .?�__ Q ____Depth of filter material____-/' _-._-_Total, length_____7 ________________________ S page Pit: Distance to nearest well_____________________Distance from foundation___._______________.Distance to nearest lot line---__-_____- Number of pits----------------------Lining material.----------------------Size: Diameter-----------------------Depth--------------------------------- Cess ol: Distance from nearest well----------------Distance from foundation-- ---------------- Lining material____-._______________________________ ❑ Size: Diameter---------------------- --------------Depth------:---------------------------------------------Liquid Capacity----------------------------gals. r . Privy: Distance from nearest well-------------------------------______________-_Distance from nearest building---------- ❑ Distance to nearest lot line----------------- - ------- -------------•---------------------------------------------------------------------------- Remodeling and/or repairing (describe)------ •-------------------------------•-----------------------------------------------•-------- 1 ---------••--------------------------------------------------•------------ ------------------------------------------•-------------------------------•---------------------------------------------- ________ 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 San ,Joaquin Local Health District. �p ---- -- - r --'i- --------------------------------- Owner a(Si (Signed) ------------------ -- --- om _By----- i . ---- -(Title)--------- _ --=�-- ---#.' _ ------- - ------- --------- :.: (Plot plan, showing size of lot. location of system in re n to wells,6uildirrgs; etc., can be pla,ced on.reverrse side). ,; FOR DEPARTMENT USE ONLY W APPLICATION ACCEPTED BY--- - -------- - --- - ------------------ - ----- ----------------------------- DATE-------7- � ------------------ REVIEWED BY-----------------------------------------------------------------------------------•---------------------------------------- DATE------------------- --------------------------------------- BUILDINGPERMIT ISSUED_-------------------------------------------------------------------------------------------------- DATE--------------------------- --------------------------------- Alterations and/or recommendations:-------------- ------------------------------------------••------------------------------------•-•------•----------------------•------------------------------- -----------------------------•--- ------------------------------------ ------------------------- -----------------------------------------------------------------------------------------------•-----------. ------------ . _ -- ---------------------------------------- -------------------------------- --------------------------------------------------- ------------------------------------------------------------------------- ----------•-- FINAL INSPECTIO BY:-:_ `___-_��-- _ -- Date------------ - -� --------- -------- ...-----� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Na:elton Ave. 300 West Oak Street 124 Sycamore Street .205 Wes+9th Street Y ti ,California Lodi,California Manteca,California Trac, Stockton,California F ES 9 REVISED B-59 31A 3-'63 F.P.CD. 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