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vRurnt,t ubt: i i --------------------- - --- ------- ---------- ------------------------ -------- APPLICATION FOR SANITATION PERMIT Permit No. 1..,��_. -3 - ------------------------- ------------ --------- ------ s (Complete in Duplicate) This Permit Ex ires T 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. JOB ADDRESS AND _CATION_ 1__7 3--- _ Owner's Name------------' l S ------ K� _ /11 t?. } ` Gl----1--. itir/1 f3 . ------------------- PhoneAddress....................,e -----------------------•------------------- ` `------- ---------••-------------------- Contractor's Name ------------------------------------------------ Installation will serve: Residence ❑ Apartment House ❑ Commercial [J"'Trailer Court [:I Motel ❑ Other ❑ Number of living units: Number of bedrooms Number of baths � Lot size _-____- Wafer Supply: Public:system ❑ Communit 1 Y system E] Private z Depth to Water Table -------- ft. Character of soil to a depth of 3 feel: Sand ❑ Gravel ❑ Sandy Loam ❑ lay Loam ❑ Clay ❑ Adobe [1 Hardpan ©f Previous Application Made: (If yes,date____________________) No [] New Construction: YesNo . TYPE OF INSTALLATION AND SPECIFICATIONS: ❑ Q�FHA/VA: Yes El No [}-- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank; Distance from nearest well________________Distance from foundation--------------------Material--------- ----------- ---- - ------------ ❑ No. of compartments-------------------__----Size----------- ----- \ ' ---------------Liquid depth---- ---------------------Capacity----------=------------ Disposal ield: Distance from nearest well / .Distance from foundation_f, f_______.Distance to nearest lot Number of lines__-.____/------- -- ----------Length of each ______.Width of trench.__ _ _'__ _--._-__. Type of filter material__�0.(��p�o_�--Depth of filter materiaL_l�``�-----_ length---- Seepage � p g Yp fl ---Total length--- -�------- ---------•----- � $ee a e Pit: Distance to nearest welll(� !. Distance fr m foundatioriZZ,S_'• --.Distance to nearest lot line_ Number of pits____._l__________Lin-n material_-�iP . g �-------Size: Diameter--- -- - ---Dept h----.� ---- esspool: Distance from nearest well-----------------Distance from foundation__.--------.--------Lining material____ - El I Size: Diameter------�--- ------ ---------- -----Depth--------------- - ---------- --------- -- .--____________- ----- --Liquid Capacity --------------------------gals. - Privy: Distance from nearest well _______---------- ------------------------------Distance from nearest buildin ❑ Distance to nearest lot line--- 9 -------------- --------------------- -- Remodeling and/or repairing (describe'-----_ ------- 1.--------------------- ------ ---------- --------------------- ----------------------•----- •--------- -------------------------------------------------- ------------------------•----------•------------------------------------------------------------- I hereby certify that I have piepai'ed this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules.and regulations of the Sari Joaquin Local Health District. (Signed -- --`(--- .�"." , i _ n Contractor) _ - Con rac or) BY; i-rte -' —�' --- (Title) �..! -. � ra or (Plot plan,showing size of lot, location cf syst m in relation to wells, buildin s, etc., can be laced on reverse side). g p FOR DEPARTMENT USE ONLY ,_!5!, ..... 1 APPLICATION ACCEPTED BY ► rzy,-yf• ---- - -- DATE__?. j" '"rs----------- 1 REVIEWED BY / ------------ -- - ILDING PERMIT ISSUED---------------------------- DATE--/_u-_If=C---�------------ �._,..a. i�c . - --------------------- DATE.- - A terafions and or re ommertdatians::.�"_�"____'-".----__. :_ � � ------ -------- -------- -- M------------------------------------- -- -=- ------ - i e ---------------------- ----------- --------------------- ----- -------- ----------=------------------------ FINAL INSPECTION BY;-- r -------- Date... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. $ 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stecklon,California Lodi,California Manteca,California Tracy,California F.P.CO.