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F FOR OFFICE USE: <7 5 -- ------------------------- ----------------- ---------- APPLICATION FOR SANITATION PERMIT Permit No. . ----- ------------- -------------------------- -- - ------- (Complete in Duplicate) 7 Date issued f---� -- ------------------------ This Permit Expires 1 Year From Date Issued # to construct and nstall the work herein described. A y Application is here made to the San Joaquin Local Health DNrric for a permii This application is made in compliance with County Ordinance -' -. JOB ADDRESS AND --LOCATION_ --- -- Phone------------------------------------ __ ____ ----- -- ---- -- - ------------------------------- ------------ ------------- Owner's Nam"-ftt!- Address_.__.._._ _ ..-------. Pone----------------------------------- A Contractor's Nam ------- Motel ❑ Other ❑ Installation will serve: Residence Apa tment House [ICommercia4 ❑ Trailer Court [I Number of living units: J----- Number of bedrooms __ umber of baths Lot size ------ - Private th to Water Table -------- ft ❑ Water Supply: Public system F1 Community system [IDepCla Adobe❑ Hardpan Character of soil to a depth of 3 feet: Sand C] Gravel El Sandy loam ❑ Clay Loam [I 8Y No ❑ Previous Application Made: (It yes,date-----------..... - I No 171 New Construction: Yes E] No ElFHA/VA: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool permitted if public sewer is available within 200 feet.) ff(� Material____ 1 p 0 j Dista/n�e roam f u dati ,____.l--n------- 7 r E ® q p Septic ank: Distance from nearest well----- -- i quid de th______[�---------- Septic _ Capacity--. - -' --- ----Size------ ---- F - --- -- No. of compartments____ ___ __ ___T � - `_____-Distance to nearest lot line-' ---r— Wjdtk - Distance from foundation- _. _ -- Dispos Field: Distance from nearest well. Len th of each line_____- ��-- of trench.___ - -------- � Number of lines----- �.� g �' ------------------------ --- ------- mac ----Total length Q Type of filter matenal______Sr - -Depth of filter material----- g _ _ __Distance from foundation-__ V ---.Distance to nearest lot line---------- Zag Pit: Distance to neares# we ----- ------- - - "-------De th__.----- ------------------------ Seep Number of pifs---.--cR-----------Lining material_--- -'-•---.:Size: Diameter----- -------- p Cesspool: Distance from nearest well ______________Distance from foundation-------------------- Lining material— Size: Diameter----- --- --- ------ ----- ------ Deth--------------------------------------------------- Liquid Capacity tY -•----- gals. ❑ �-' Privy: Distance from nearest well------------------------- Distance from nearest building------------------ ----------------------- ❑ Distance to nearest lot line-------------------------- - ----------------- o - Remodeling and/or repairing (describe ----------------------------------- -------- ----------------------- ---------------------------_-_-- -------------------------------- --------------- - --------------•---------------- --------------•-------- ------------- ---------------- -- --- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify the nahrulespandaregulations olf the San JaaquinhLocalkHealltheDistnc{n accordance with San Joaquin--C---o-u--n--ty ordinances, State laws, a (Signed)----- ----- - -------------------------------------------------------------- ---.-__--__{�r�and/or Contractor) --0 la �T ------ --- --- ---- --- -------- (Plot a ----- ------ --- Bn ho Nd {Plot plan, showing size of lot, location of system in relation t ells, buildings, etc., can be placed on reverse si e. FOR DEPARTMENT USE; ONLY DATE----- --------- --- APPLICATION ACCEPTED BY - DATE REVIEWED BY------------------- ---- ---------- ----------------------------------------- ------------------- --------------- - ------- ------- - DATE------------------ ----- ----- ---------------------------------------------- BUILDING PERMIT ISSUED ------------------------------------ --------------- Alterations and/or recommendations:.______.____.____.__-.- - __________________ Date.... ------- --- --- � ----- - - ----------------------------- - e. FINAL INSPECTION BY:___ . K '= SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellen Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Lodi,California Manteca,California Tracy,California Stockton,California