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FOR OFFICE USE: ............ •--•--....------ APPLICATION FOR SANITATION PERMIT Permit No. ---------------- .................... -------------- ..........--•••---••--•--_...._."------------------------ (Complete in Duplicate) Date Issued •.-.••-___•.."•----___...._...__-._.-- This Permit Expires I Year From Date Issued . descrImed. Application is hereby made to the San Joaquin Local Health District for a permit to construct and* install the work herein This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION, 4 Phone------------------------------------ Owner's Name------ 141,4 -----------•....................... Address---------------.- .....-•----------------- ......... ; ------ ; ........ I ---- - ---- .... . ..... ................ Contractor's Name------ - ---------------------------- ............... ------------- ------------- --------------------------------- Phone----------------------...--------- Installation will serve: Residence Ix Apartment House [I Commercial E] Trailer Court [] Motel E] Other 0 '? /L 1W ................. Number of living units:._.... Number of bedrooms Number of baths --- I.. Lot size -64-A-1-2-nA --- 0-� -------- Water Supply: Public system El Community system El Private Fj Depth to Water Table &.P- ft. Character of soil to a depth of 3 feet: Sand [] Gravel [I Sandy Loam Do Clay Loam F-1 Clay E] Adobo 0 Hardpan ❑ Previous Application Made-, (if yes, date____________________} No �I New Construction: Yes C? No [] FHA/VA.- Yes [1 110 ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted -if -public sewer is -available within 200 feet.) Septic Tank: Distance from nearest well.j470 -------- Dista from fouriclatiort.-I-�...`.... ... Mateyr.-01-64-rl --------------- No. of compartments. Qom.... ... Liquid dep)h --------.. ---------- pa i /0' nearest lot line from founclati ....... ------ Distance to ----- ---------- Disposal Field: Distance from nearest well.'...... Distance fr Number of ... .Length of each line_._.-_-.--. Width of french A -Y..1.1-1 .................. ........................... m r, ------------ Type of filter afe Depth of filter materia .... J ........ ........ Total length---t�6 Seepage Pit: Distance to nearest well ---------------------- Disfance from foundation ------- .......... .Distance to nearest lot line---____._.___.._. A ❑ ine--------- 171 Number of pits.... ............. ----Lining material-_--.---.-.-..-_-_-- Size-, Diameter --------------- ....... Depth --------------------------------- Cesspool: Distance from nearest well -------- ------- Distance from foundation ...... ............. Lining material___._.... ----------- --------------- El Size: Diameter-------------•------- -------------- Depth. ...................... — -------------------------- Liquid Capacity ...... --------------------- gals. Privy; Distance from nearest well ------------------------------------------------- Distance from nearest building... ---------------- ......... — ---------- 0 Distance to nearest lot line-------------------- ----................................ --- .......... Remodeling and/or repairing (describe): ------------------- ------------ ---------------------------------------------------- - ----------------------------------------------------------------- --•-----•---------•------------- ---------------------------------------I..................----------------- ------------------------ I ------------------ ...... I ------------ I ..... . ........ .............. ---------------------------------- ---- - ---------------------------- .........----------••--•---••-•--.------- ------------ —. ----------- ----------••-"---•------- -----•-----•- -----------I--------------------------- — ....... — -- - --------- --- ------------------------------------ --- ----- I ---------- - ... ----------- --------------- --------------------- -------------------------------- 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. ................. .......................... (Owner and/or Contractor] ................ ----------- ---------------------------- ......... - By:- ---------------------------------- (plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY -------------- ---------- APPLICATION ACCEPTED BY--..- ----------- - ...... ....... ------------------------ DATE - - - REVIEWEDBY------------------------ -------------------------- ----------- * -------------- -------- DATE.........---------.....---- ----------------------------- - BUILDING PERMIT ISSUED ---------------------------- ------ - -- ---- ------ - Alterations and/or recommenot-on74---�IV----I------ 4 .......... ------- -- --------------- -------------------- ------------------------ ---------------------- - --------------- ----------------- -------------- ------------ ............ ------------- .......... ............... ----------- -- --------- ........................... I -------------------------- I ---------- — ----------------------------------- ----------- ............. ------------- X-1 . FINAL INSPECTION BY:.--- ------------ ---- Date .. ... ........ .. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Holeltan Mt. 300 West Oak Street Sfqck.tcn, California Lodi, California ES 9 REVISED 6-59 am 3-63 F.P.013, 124 Sycamore Street 205 West 9th Street Manteca, California Tracy, California