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FOR OFFICE USE: u�fJ/ F ---- - - / 7 f �------- -------_ __ aAPPLICATION FOR SANITATION PERMIT Permit No. ...1__�//j/ / I( {L -------------------------------- (Complete in Quplicate) `T//� f ----------------- This Permit Expires 1 Year From Date Issued bate Issued ___.-._..___.f..._.__. Applica+.pion 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. JOB ADDRESS AND OCATION-------------- r__.. 1,fp� l ---------------------------------------- I=-------------------------- Owner's -------------.. ------------Owner's Name------ !•-� .-------- ---------------------------------- Phone----'•---------------------------- Address---------------------------------------•-r ' �) Contractor's Name-------- ---- ----- _:_..-•------------------------------------------------------------------ Phone__ � ,,------- Installation will serve: Residence`K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1___ Number of bedrooms __9L7Number of baths __Z-Lot size`7!6?r^'__.__. -------------------- Water Supply: Public system ❑ iCommunity system ❑ Private I] Depth to Water Table&?.'_)__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ffi Hardpan ❑ Previous Application Made: (If yes,date--------------------) No W New Construction: Yes ❑ No W FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan • , Distance from nearest well_______________Distance from foundation--------------------Material-____________.._______.____._-._____-_________- ❑ f7 Y1INo. of t t com armens_.______--------- p --------Size--------------------------------Liquid depth-----------------r-- -----Capacity-------------- -------- D;sposal - Capacity-------------- -------- Disposal Fiel : , , Distance from nearest well--- --------Distance from foundation-________________.Distance to nearest lot line----------------- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type --------_---- ------Type of filter material-------------------------Depth of filter material----------------------- length--------------------._.------._____________ r Seepage: Pit: Distance to nearest well _ _ ___Distance from foundatDistance to nearest lot line.......]_--.__-_. C 1 Number of pits------- ------------Lining material_s5'e_ G./�5ize: Diameter----------�-'-`- Depth------ _t- - ---------- Cesspool: Distance from nearest well-----------------Distance from foundation---.---------------.Lining material_--------------------------------.. ❑ Size: Diameter-----------------------------------.Depth----------------------------- ---------------------Liquid Capacity_.-----------------------gals. P Privy: Distance from nearest well-_______________________________"'_.___...._Distance from nearest building---------------------- ❑ Distance to nearest lot line-------------------------------------------- -----------------....-----------------------------------------------------'-------------------- Remodeling and/or repairing (describe):----------- ___ _� r --�� ,�r= x -; --------------------- -•------------•-----------•----------•------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- ---- -------------------------------------------------------------------------i•--•----------------------------•--------------------_____.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. (Signed)---------------- � � i4 - ------------------ ------------------------- (Ow er and/or Contractor) G - (Title)-- ----- - ----------------- - --- -- ------ (Piot plan, showing size of lot, location of system in relati to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY r DATE REVIEWED BY------------------------------------------------------------ ------- - -------- DATE BLiILbING PERMIT ISSUED .._ ------ — -�------------------------ DATE--------------------%----------- ------- Alterations and/or recommendations:_______. `� � . `` f G _ � -------•---- ' Y, ----------------------------------------------------------------- ----- - -------------------------'-------------------------------------------------------------------------------------------------------------- 1 - � - -------------- -------------------- -------'------------------------ -------------- ---- --------------------------------------------------------------- -------------------------------------- --------------...---- ------- ------------------------------- ------------------ ------------------------------------------------------------------------------------ -------- -------------------------------- FINAL INSPECTION BY:.--- ------•-- Cry' ---------- Date------� f� f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Slockton,California Lodi,California Manteca,California Tracy,California ES 9 RIMSEG 13-59 31,4 3-'63 F.P=.