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FOR OFFICE USE: q..14- 66 ------ APPLICATION FOR` SANITATION PERMIT Permit No. ------ -- -------- -------------------- -------------------------------------------------------- (Complete in Duplicate) 0 3—ee _ ___ _ This Permit Ex ires 1 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 isrmade-in compliance with County Ordinance No. 549. 1410^4-1,(F.,C4 Uw,fr F JOB ADDRESS AND � �----- •----- � J� .: > ----- -- ••- . s < i� ' Phone ' Owner's Name------- - - - --- ��--- - -------------------------------------- ------------------------------•-•-----•---------- ----------------------- -- Address------- -- _ - Contractor s Name------ 0' ! --=--------------------------------------------- Phone ----------• ----------------- Installation will serye: Residence k5,--^fp-a�-r-tment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _l-- Number of bedrooms _el._ Number of baths _A-- Lotsize/! -p -----------------•---- Water Supply: Public system El Community system [D Private Depth to Water Table'I�t-_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe KV-*Fiardpan Previous Application Made: (If yes,date-------------- ----) No Vr"'New Construction: Yes ®/'No ❑ FHA/VA: Yes �Io ❑ ,;,j TYPE OF INSTALLATION AND SPECIFICATIONS: = (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f Septic Tank: Distance from nearest well__ ______Distance from foundatio f/C9--------_.Mater I- ,ed-", mac- ___-- ------ No. of compartments-, -----------------Size47-- _W<ooiquid depth------ ---------------Capacity .----- Disposal Field: Distance from nearest well__ ------Distance from found f- n-_��__ ___.Distance to nearest lot line_________ -- g Width of trench _ _ T e of filter materia __� _ Depthhofffilterlmlateria Number of lines_._ _ , > ___ �:---�� yp 4/ Total lengtk�__.� ? Seepage Pit: Distance to nearest well------------- --------Distance from foundation--------------------Distance to nearest lot line_____..._-_.__.._ ❑ -Number of pits---------------------Linirg material-----------------------Size: Diameter-----------------------..Depth--------------------------------- d � Cesspool: Distance from nearest well--------------___Distance from foundation----_._.__.__,._._.Lining material------------------------------------- Q j ❑ Size: Diameter-------------------------------------Depth--------------------- --------------------------.-Liquid Capacity ---------------------------gals. s Privy: p Distance from nearest well----- -------------------------------------------Distance from nearest building-----_------------------------------------ ❑ ( Distance to nearest lot line--------------------------------------------- ------------------------------------------------------------------------------- ------- --- G Remodeling-and/or repairing (describe}: �15�111tz---- + -- ----------- -------------------------- • --------------------------- --------------------------------------- i ------------ ----------------------------------- ---------------------------------------------------------------------------------- Ijiereby certify that I hive prepared this application and that the work will be done in accordance with San Joaquin County .ordinarices, State laws, and rules and regulations of the San Joaquin Local Health---- District. �' ----- --- Contractor by:------------------------------------------------------------------------ - - = = (rtlel - - ----- (Plot plan, showing size of_lot1 location of system in relation to wells, buildings, etc., can be placed on reverse side). µ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --------- ----- ---------- -------------- -------------------------------- ------ DATE------~-I--r---� ------------------------------------ Y ; RIEWED BY -------------------- ------- -------------------- -- ------------------- ------------------ ----------- DATE NG PERMIT ISSUED------------- -------------------- ------------ ---------------------------------------- DATE ---------------------------- Alterations ---- f Alterations and/or recommendations:-©-K ---(6 -----01—CA - ----------- -------- TM.f ��S f �� ------------------------------- t - -------- ---- .... - - ---- ' - -------- -- •----- --------------------- -- ------ ------------------------------------------- ----- ---------------------------- ----- FINAL ----FINAL INSPECTION BY-- Date-------- -------- ------ --------- - ----------------------------------�----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street / 205 Ts,t 9th Street 5tocklon,California Lodi, California Manteca, California f� cy,California