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4' w [' / � 1 1F \ � V 1 �l WWW lY o APPLICATION FOR SANITATION PERMIT Permit No..-_�-�.�•a-- AK (Complete in Duplicate) Date Issued This Permit Expires l 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 described. This application is made in compliance with County Ordinance No. 549. — ---------------------- JOB �- ----------- ------- ------------ ----- ------------ --•------- JOB ADDRESS AND OCATION ----,----- ------ = �.�..�._ -- ---- Phone ---------------------------- ---------------- ---------------------- Owner's Name ------- •-�---•� --•--•----� ! < / ---- Address ------- ------ f!/ �'--�--- ---- ------ Phone - _ Contractor's Name_____________________ � - Motel ❑ Other Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ ' __ Number of baths __/__ Lot size ___-ttJ-.r-�i -------------• ---------- ' Number of living units: _�--- Number of bedrooms _� i Water Supply: Public system ❑ Community system ❑ Private �epth to Water Tab❑le/�ft• Adobe Hardpan Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ ❑ ❑ Previous Application Made: Yes ❑ No Construction: Yes ❑ No ET' 'FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No'septic tank or cesspool permitted if public sewer is available within 200 feet.) �( L / Mate4__`__--�---- -- - ------------- Septic Tank: Distance from nearest well -:M._____-. Dista fVro foundation__,/ - --- - . „�-�F��-•---- -- Liquid depth----�-- Capacity --V �- ❑� op No. of compartments___._ _ Size_ __ �' - bisposal Field: Distance from nearest welL�S`0--___Distance from foundation.�fi-�-------Distance to nearest lot li �.S___---.__ --Length of each line ...... Width of french _2..41_1_______________________ L Number of fines g `---Total len tip ------- -----------��e-------•---- Type of filter material__--�L�Depth of filter materia --------- /T 5 Seepage Pit: Distance to nearest well -____________________Distance from foundation____-___.-..__-.__. Distance to nearest lot line ----------------- --------------------------------- 1-1 , Number of pits --- ------------------Lining material -------------- --------Size: Diameter -------------- --------.Depth } Cesspool: Distance from nearest well -------------__Distance from foundation -------------------- Lining material ------------------------------------- ❑LiquSize: id Capacity ----------------------------g \ Size: Diameter--------------------------------------Depth-----=------------------- --------------------- � -Privy: Distance from nearest well-__------------------------------ -------Distance from nearest building_________.-----------------------------� ❑ Distance to nearest lot line ---------- -------•-----= ------ ------------ --------------- ------ Remodeling and/or repairing (describe): --/-.,^ --- --- �rf,0� -- ---------------------------------------------- --------------------- -------------------------------------------------------} ------------ --------ation ------ ----- done I hereby certify thaandhrulespandaregulations olf the SanJoagwnhLocalwork Heal heDistric+n accordance with San Joaquin County ordinances, a i (Signed} -------- caner and/or Contractor) Q o �- �. - �[�- (Title) -- By:-------•------------ ----------•------- - -----�-r<n-�- - ---- - (Plot plan, showing size of lot, location of system i_ relation tow ,buildings, etc., can be placed on reverse side}. FOR DEP USE ONLY APPLICATION ACCEPTED BY --------------------------- ------- -------- - - - - -- ---------------------------------------- DATE------ --w----------------------- DATE ----------� ----- ---- REVIEWED BY BUILDING PERMIT ISSUED _DATE. - Alterations and/or recommendations --------------------------- ---------- --------------------------------------------------------------------- ------------------------------ ------ ------ -------------------------------------------- :� ---------------------------------------------------- I ------------ ---------------------- ------------------------------------- 11 ------------------ -------- ------------------------------------------------------------------------ ---- ----- ----------------------- ecommen a+ions:._____...________________._._____.--- ---------------------------------------- ---------------------------------- -------------------- --------------------------- ------------------- ---------- --- FINAL INSPECTION BY:.- -- --------------------------------------- Date---- ------ ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Sfockfon, California 300 West Oak Street 132 Sycomore`Sfreet 814 North "C" Street Lodi, California Manteca, California Tracy; California ES -9-2M' Revised 8.'59 F.P.eo. -