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FOR OFFICE USE: ---------------------------- ---------------- ------ - �� APPLICATION FOR SANITATION PERMIT Permit No. ....................... ------- ----------------------------------------- (Complete-in Duplicate) 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 described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION - - --------•--------- ----------------------------------------------------------------------------•--------------- Owner's Name----- -- ' -,- ---- --------------------------------------------------- -- ---------------------------- -------.-. Phone----------------------------------- Address----------��?'`—_--- ---------------------- -=--------------------------------------- -- ---•------------------------------------_- Contractor's Name----0 -- .2 � � --- ------------- ---- - ------------------------- -------------------- Phone------ ---------------------------- Installation will serve: Residence R�'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ Number of bedrooms ___G_ Number of baths___I.._ Lot size __ho- -- - --- ----------------=-------------- �[ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table 4!9. _ ft =moi Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay F1 Adobe 3--Hardpan ❑ W* Previous Application Made: (If yes,date-----------,_.. ) No [!111/ New Construction: Yes ❑ No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Senk: Distance from nearest welL___.._...__.__Distance from foundation__________________-Material _____._._.____.__..____..._.___._----------- ptic .._. �� No. of compartments------------------- --Size------------------- - ---- --•---Liquid depth---- ---- ------- ........Capacity..-.- ----------------- Disposal Field: Distance from nearest well...5 ..._Distance from foundation_._ &----------..Distance to nearest lot -_..... i ❑ Number of lines._--_I----------------------------Length of each line--/a- .-.-------...Width of trench'I_.'r----------------------- Type of filter material---70(e!�..__-Depth of filter material____.-tg------------Total length-------/a---_________________________ Seepage Pit: Distance to nearest well./6.6--------___Distance from foundation___/o---_-______.Distance to nearest lot line--- ..____.- ❑3— Number of pits---f--...............Lining material_._Gj_A'_. Size: Diameter_____3.3.r'_..----Depth........ZJ7---__. Cesspool: Distance from nearest well ................Distance from foundation.__...-..-------- ..Lining material---------------- ----- -------------- F1 Size: Diameter- -- --------- ----- ----------------Depfh----------_--- ------------- -- - - - -------------Liquid Capacity.- -------------------------gals. Privy: Distance from nearest well------------------------------------ Distance from nearest building-------------------------------.--_--.._. ❑ Distance to nearest lot line -------------------------- - -- - -----------=--------------------------- --------- -- ------------------------------------- -------- - Remodelingand/or repairing (describe)--- ---------------------------------- ---------------------------------------•------------ ---- ------------------------------------------------------- --------------------------•------------------------------------------------------------ --------------------------•---------------- -------------- ------------------------------------------------------ ---------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. -� (Signed)----------------------------- ---------- -------- ----------------------- ...... ---------------------------- -------- --- ------------------(Owner and/or Contractor) By:------- --------------------------------------------- ---------r ------- ----------------------- Title (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_ 51!7 ----------------- --------------------- DATE--//4 -ems___-7----------------------------- REVIEWEDBY---------------------------- - --------- - ------------ .- ----------------- -- ------------------- DATE----------------- BUILDINGPERMIT ISSUED-------- ------------------------------------------------ ----------- ------------------------ ----- DATE--------- - -------------- ---------- - Alterationsand/or recommendations:.---- ------------------------------------- - --- ---------------------------------------------------------------- -•-------------------- ----------------- ------------------------------------- ----------------- ------- ----------------------------------------- ---------------------------------------- i FINAL INSPECTION BY:_. .. Date jlv�(---.�r --------------------------------------------- - l SAN JOAQUIN LOCAL HEALTH DISTRICT r 1401 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 5lockfan,California Lodi California Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press I