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FOR OFFICE USE: --------------------------------------------------------- ------------------------ APPLICATION FOR SANITATION PERMIT Permit No. .� � _r {Complete in Duplicate) 1 --------------------------------------------------------- This Per 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, 02 0_Z� OB-ADDRESS N� .. ^OC TON � � : t - _r� ----------- ------ Owne'r's Name - ------ .------ ---- -- ------------------- ,. hone-----------------=------------------ -----'--- k� _ �-. s--------•--------------------------------------------------- AddressContractor s Name ---- •--- 3.es_ --- - r :. Phone----------------------------------- - Installation will serve: E Residence Apartment House El Commercial ❑ Trailer Court ❑ Motel E] Other E] Number of living units: 1-___ Number of bedrooms___ Number f baths _!--_ LOt size Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -_.__-.- ft. Character of soil to a 1.1.depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E]. Clay [dobe❑ Hardpan ❑ Previous Application Made: (If yes,date-------------- _-.__I No ❑ New Construction: Yes ❑ - No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: f - (No septic tank or cesspool permi#ed if public sewer is available within 200 feet.) A- Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Materiaf_.-_------------------------------_------------ ❑ No. of compar{merits-------------------------Size------------------------•-------Liquid depth---------- ------ ----Capacity----------------------- Dispos field: Distance from nearest well--- F-.____Distance from foundation.-'. -4---.___._-Distance to nearest lot line-- -�---- Number of lines-----------/-------- Length of each line------I-4s_1-_�---_--- Width of trench- 7- -----------f--------------------- h Type of filter.material------___ --__De.ptil of filter material--------,�Q ._Total Length_--. 8-jP____________________ Seepage Pit: Distance to nearest well-------------------- Distance from foundation--------------------Distance to nearest lot line--------------__- `�- ❑ Number of pits-- _- Lining material-----------------------Size. Diameter_--------.#---------- Depth Cesspool: Distance from nearest well-------------- Distance from foundation--------------------Lining material 1 ❑ Size: Diameter-- =-- ---------------------- ------Depth-------------- ------------------------------- -----Liquid Capacity_. ---------- gals. Privy: _ Distance from.nearest-well-------------------------------------------------Distance .from nearest,building---___---._----_--------__- ❑ Distance to nearest lot line ----------------------- -- ------------ -----•-------------------------------- Remodeiing and/or repairing (describe):-------------------------_-- ------------------4- _- i ��-->-- ----------- -�p = rd .rP--Y - ----------------------------------------------•------------ ---------------------------------- ------------------------------=----------------------=----------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin.County ordinances, State-•la , nd rules and regulations of the San Joaquin Local.Health District. (Signed)------------- --- and/or Contractor) -- - ----- ----------------- i i = ---------------(Title)--------------------------------- ---------- -------------------------------- By: ----- -- BY� - - -------------------------------- (Plot plan, showing size of lot, location of stem in relation to wells, buildings, ate., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYQATE- - ---1'' ��--------------- -M -- ---- - - -- -- - ------------------- REVIEWEDBY-_�------------------------------------------------------------:_------------------------------------------------------------- DATE -------------------------------------- BUILDiNG PERMIT ISSUED j�------------------------------------------ -------------- DATE --------------- Alterations and/or recommendations:-.. —.- ---,--=.e==-b -- ------------•------------- -------•------------------------------------- - ------------ I- -- ---------------------------------------------- -- ---------•--------------------------- \ �,-;5 ----------- ------------ - - _ i --- ------------•-------------- FINAL INSPECTION BY:- ''[ -----t---------` ``'"�f_""". Date-------- ------------ L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street S Slocklon,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 9.59 3M 3-•63 F.P.00. 3