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t9D- � j APPLICATION FOR SANITATION PERMIT Permit No. —//. o �! (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__L _�� ____ . � Owners Name ��l�� gr`_. ' _ ------------------------------ Address --------=---------------_ _ Phone Address---------------- -----------------------------------------` f Contractor's Name------------------ -- P ----------------------------------------------------------- Phone-------•--------------------------- 1 Installation will serve: Residence [g--fSpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ " Number of living units: ___�___ Number of bedrooms _'__ Number of baths __/___ Lot size _ _ _�_ i��_ ________________________ Water Supply: Public system Community system 0: Private E] Depth to Water Table /ft. i Character of soil to a depth of 3 feet: Sand E] Gravel E] 'Sandy Loam E-] ClayLoam ❑ Clay E] Adobe �ardpan El ❑ k Previous Application Made: Yes I No-E] New Construction:;Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ l TYPE OF INSTALLATION AND SPI_CIFICATIONS: ,rT (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S ptir k: ' Distance from nearest well_________________Distance from . foundation___________________.Materia!__...__________-__.__---_---_----------__.___.._- No. of compartmnts- -,-------------------Size------- y---------------Liquid -------------------------- # delath_ ------- - -----•------Capaci#Y----------------------- , Disposal Field: Di from nearest well._�,_..___._Distance from,foundation--------------------Distance to nearest lot line_____'__________ 5014 Number of lines------------- '-------------------Length of each line----_------:----------------_.Wid#h of french.----------------------------__-•-- Type of filter material-------- i-------------Depth of filter material----_-----------------Total- length-----------------:----------------- ---- i `-�-- See age Pit: Distance to nearest well----- Distance fron �lo'Undation__.A7__.___Distance to nearest lot line________..: ~ '. Number of pits_�__�µ _s g �. __Size: Diameter_ !� ..___Depth___��__,__� �---.__---Linin material-- _ _ _ "-- ,.�,�____-- Cesspool: Distance from nearest well-----------------Distance from foundation.-.----------------.Lining material,-------._.___.____.____________.___. ❑ Size: Diameter.-#-----------------------------------Depth-----------------------------------------------------Liquid Capacity-----------------------___gals. Privy: Distance from nearest well. -------------------- ----- ---- - Distance from nearest building (^� - ., 9------------------------------------- - -. ❑ Distance to nearest lot line------------------------------ '---------=----------- *-------------------------------------------------------- ---------- Remodeling and/or repairing (describe)------------------- --------•--------------------------------------- •------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. 4(Signed)---------- -.- --- -------------------------------------------- = --------- -----�or Contractor) By:----------=................ ------ --- ------> -------------------------------------- ------(Title)---- ` ` (Plot plan, showing-size of lot, Narration of system in relation to wells, buildings, etc.; can be placed on reverse side). a FOR DEPARTMENT USE ONLY oIONACCEPTED BY T- - == -. DATE 1 � - ® --------------- By ------------------------------------------------------------------------- DATE- - 'ERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------------------------- nd/or recommendations--------------- --- ------- -•--- -------- ---------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------7 "----- i I '� ---------------------- Date TION SY:. ----- - ------ -•----------- ti SAN kJOAQUIN LOCAL HEALTH DISTRICT icaa Street 300 Wes+ dak Str`aat S • �► ,132 Sycamore~Street i 814 NorA "C" Street 1 fifornia Lodi,-California Manteca, California Tracy, California l •,'59 FY.Co.