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41-At. �s ------ APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) G1/ �S Date Issue----------------- ---- d 9 Application is hereb made to the San Joaquin Local Health District for a permit to construct and install the work herein described. App Y f This application is made in complionce'with County Ordinance Na. 549. { J., - JOB ADDRESS AND LOCATI N- 67 ------------------------- Po n ------------ -- --------------------------------------- "Own' ---------e ,t - Name--------------- - f } ' - -----•-- --�-� — ... ---------------------------------------- Address---------- ---- --------------------------------------- --------- t — --- ----•-•---- Phone---------------•------------------ Contractor's t Installation will serve: Residence R Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ { Lot-size _ ---- ----------------------- - Number of living units: __ Number of bedrooms -tR.- Number of baths _ Water Supply: Public system.❑ Community-system ❑ Private'[ Depth to'Water Table - ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loem ❑ w Clay Loam E] Clay El of ❑ Previous Application Made: Yes El .iNo � •New Construction: Yes ❑ No [7��FHA/VA: Yes [I No 9}r l TYPE OF INSTALLATION AND SPECIFICATIONS: i I (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ` v AA Septic Tank: Distance from nearest wel __j_ --_---Distanc fr m fo ndation_ .---.---Matpri�L_�_[.�---- --- -- --------------------• �� No. of'compartments.__-_ _ `--------Size__ -X. -` Liquid depth__ _-- ----------CapautY-- ----- [ 1 f Disposal Field: Distance from nearest well-- �;---- Distance from foundation__! ------------Distance to nearest I t lin�fe _------..- �_ ____.__.Width of trench.__ Number of hnes_____"_/...... Length.of each line---4(-- pp- - r - Type of filter mate�iaL _ --- Depth of-filter material------.LO_-.i�_--.Total length_____,��------------------------ f , / �— C[�_ __.:__.Di `/e to nearest lot line__ ______.__ Seepage Pit: Distance to nearest well____� �-_---Distance Ira fou ation___ ' Lining Material _ r�Size. Diameter- � ___.____Depth_____ --------------- . Number of pits.`_"°_l_.___.__-- _ . Cesspool: Distance from nearest well-----------.-____Distance from foundation--------------------.Lining material----------•------------_--------.------ �1) Size: Diameter.-- Depth =' = ` =------ -- `= Liquid Capacity gals. w --:- -- p T ;' Lance -from nearest building---------------------------------------- Privy: Distance from-nearest well - - - -- - - - -Dis ----- - - s Distance.to nearest lot line:_ -::-----' - ij ' Y " � -•-- -- Remodeling and/or repairing (describe:___-_ ._ -- . - f ' r --------------------------------------------------------------------- - ------------ 1 r : -----------------------•--------- --•------------,------------•------•• a I hereby certify that-I have prepared this application and that the work will be done in accordance kith San Joaquin County ordinances, State laws, and rules and regu ations of the San Joaquin Local Health District, 71 (Si9 act ned on r or ---------------------- ---4-4 ------k-------- BY: _ - --------------•------- --- (Plot plan, showing size of lot,-location system in relation to wells,- buildings, etc., can be place on reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- - - ------ - -- ------------ ----------- DATE_. ------'---------- -- " ----------- '^ ----- ----------------------------------- DATE- ------ ---------------------------------------- REVIEWEDBY------------=-�------• ---------••--------�• ---�---- - �-- " BUILDING PERMIT ISSUED_____-------------------------------- ---- -- ------------------- --- -------------------------I DATE Alterations and/or recommendations:-------------------------- - -------------- I ! - ------- - - --------------------------------------------- -- �-: I - ..r.-.- --- • --- -- _ - ---------------------------- -------------------•------ ------ �___ =�'� Date.-------- -.!____°." ------------7--=-----•--------- I FINAL INSPECTION �� --- .---�- -- - SAN.JOAQUIN LOCAL HEALTH DISTRICT � k ` 300 West Oak Street ` -` 32'Sycamore Street t 814 North "C" Straef l30 South American $fres} Manteca, California Tracy, California Stockton, California Lodi, California ES-9-2M z Reviseo`l-57 F.P.CO. fd