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FOR OFFICE USE: D ( I APPLICATION FOR SANITATION PERMIT Perini# No. ..............- L�- --- ------- ------------- ------------------ t� �x4 (Complete in,Duplicatel Date Issued = -------- - -- ------------------ ---- _--_-------- --- This Permit Expires 1 Year From Date Issued ------- -- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe . compliance in with County Ordinance No. 549. L �/7 f This application is madeOCATION_ --------- ---•-------------•------------------- I JOB ADDRESS AND + / ---------------- ------ ----------------- ----------- --------- Ph -------------------------------- --------------------- ------------ ---- �� one-•-- -•-----------•------.. Owner s Name."-------- Y - -------- , ,�f f - '•--------------•----------------- Address .. Contractor's Name_ -.. ._ - - ---•--------------"--------------- -------------- Phone-..- Commercial Trailer Court ❑ Motel ❑ Other ❑ Installation will serve: Residence Apartment House ❑ ❑ ' --------------- Number of living units: _"`--- Number of bedrooms _r _ Number of.baths._f-._.Lot size _ -. -- �-•---------"- : J_Vfit. Water Supply: Public system �Commuriity system ❑ Private ❑ Depth to Water Table Character of soil to'a depth of 3 feet:-, Sand ❑ Gravel [I Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe[?�'��ardpl�ano C1Previous Application Made: (If yes,date...... .......:_--) No g;-- New Construction: Yes El No [7/ FHA/VA: Yes F] ®" f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from I- nearest well------------------Distance from foundation-------------------.Material----------------------------------------------- �Ai 9 No. of compartments------ - ------Size--------------------- -- Liquid depth Capacity 1_09 ---.Distance to nearestlot line--s�--_---_- Disposal Field_: Distance from nearest well_"-...�.: --Distance from foundation_-_- - r Number of lines_-_._---__ Length of each line--"-- --------- ----Width of trench-`- _�_:---------------------- 20 c5� /� Type of fi4#er material-- -Depth of filter.material_-.� __----_--Total length__-___sem -=------- - �, �--.Distance to nearest lot line..g'�----"___ QQ Seepage Pit: Distance to nearest well-------�_ ------;Distance from foundation---_-_-_- Depths,.----______________ 00 Nu00 mber of pits-----/-----------Lining material_- ___;P Size: Diameter., , ... Cesspool: Distance from nearest well------------------Distance from foundation-..---___-.-----_'.Lining material_-.----._"-_----____.-__._---__ -. l - Depth =---------- -------------=----- -Liquid 'Capadity-.--------------------------gals. ❑ Size: Diameter------------------------- ------ p I Privy: Distance from.nearest well--------_-_,------------------------ _----_----__Distance_from nearest building------------------------------------------ ❑ ----- Distance to nearest o ine"-------------------- . /,s 2V -- - -•--------- Remodeling and/or repairing (describe)--------------------(rC --------- - ------------------------------------------- I ------------------------------------------------ --- -- --------------- --- - --- ----------------- ------------------------------ -------------------------------------------------------- �. I 1 F --- --------------I ----"-------- -------------------------- --------- I hereby certify that I haveprepared this application and that the work will be done in accordance with San Joaquin County I + tions of the San Joaquin Local Health District. ordinances, State laws, and rules and reg e [5lgned) ( or Contractor -------- -----------=--- ------ --------- ----------- --------------- -------------------(Title) [Plot plan, showing size of:lot, location of system relation to wells, buildings, etc., can be,placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ------------- DATE X-- --------------------- -- BY------------------------------------------ -- ----- . DATE------------ --------- ----------------------------------- I ------ DATE------------__------------------- --------------------------- PERMIT ISSUED------`�-•=--------- ------- --- ` .. - . Alterations and/or recommendations:------- -------------------------- ---------- ---------------------------------------------•------ --------------------------------------- --•--------------------------- ----- --- --- --------------------- ----------- --------------------- --- --- -------------------------------- � --- --- -------------------------- FINAL INSPECTION BY----------------------/-- c� `/T Date--.------_---- - - - SAN JOAQUi OCAL HEALTH DISTRICT 30o West Oak Street 124 Sycamore Street 205 West 91h Street 1601 E.Hacelton Ave. 5� Lodi,California Manteca,California Tracy,California Stockton,California ES 9 REVISED 9-S9 3M 3•'63 F.P.Go. A