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FOR OFFICE USE- - a _____________----_------------------------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------__-_-- ------- (Complete-in Duplicate) - -.--- This Permit Expires 1 Year From Date Issued 11 Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--- �+P sw '�,, a° - �= Owner's Name ---------- ------------- ---- - e- - ------ ------ ------ Phone- ------------ ••------------ - a . FAddress----------------r71SO - --- ---------------------- I - - Contractor's Name______ -------------- Phone_____._-__________._ ,1 lQ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑�� Other ❑ Number of living units: __�____ Number of bedrooms _Y Number of baths -Y. Lot size ---- --- Water Supply: Public system ❑ Community system ❑ private Depth to Water Table .____- ft Character of soil to a depth of 3 feet- Sand Gravel Sand Loam Cla Loam Clay A �3 p ❑ ❑ Y y ❑ y ❑ dobe ❑ Hardpan Previous Application Made: {If yes,date................... } No ❑ New Construction: Yes ❑ No ❑ FHA/VA- Yes ❑ No ❑ HYPE OF INSTALLATION AND SPECIFICATIONS: _,�'(No septic tank or cesspool permitted if public sewer is available within 200 feet.) _ Septi ank: Distance from nearest well--'!�!......Distance fit ro foundation-.._1_�J_.�_...Materia# ________ _______________�_.____.________. l • No. of compartments_.------�'�..........Size_ __ _.4�- ��_Liquid de th._..---_4_ '_ --------Ca acit 1-42-404- , 1 11 Dispas field: Distance from nearest well....+5_ ......Distance from foundation---{________------_Distance to nearest lot line__��_.._--___. Number of lines--------- ------____-------------Length of each line__ .---t. O-'-- -____.Width of trenchl :..____ _ _-___._ Type of falter materia}._...S_`{R.�____.___Depth of filter material---------J-4--" __-- _-_--Total length------�._QQ_______________ ___------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-_-__-__..___._ ❑ Number of pits--- ----------- ---_-Lining material--------.------------- Size: Diameter----------------------Depf'h--------------------------------- Cesspool: Distance from nearest well ................Distance from foundation-................ ..Lining material-- --------------------------------- F1Size: Diameter. -- ------- ---- -Depth--------------- ----------------- ----------------Liquid CapacifyL.-------------------------gals. i Privy: Distance from nearest well----------------------------------- -------------Distance from nearest building------11------------------______.__.__..__. ❑ Distance to nearest lot line ____________________ I1, - ----------------------- ---------------------------- Remodelin. g and/or repairing (describe):____......_____. -- ` ---•--------------------------•-------------------------- -----------------••--------- --------------------------------------------------• ----------------------------------- ------------- -------------- ------ ---------I----------------------------------------------------I----------------------------------------------------------------------------------------------I... ---------------•----------------------------------------------------I-------------------------------------------------------------------------------------------------- ---- -----------------M--------------- ------------ ---------- ll. 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)--- -- -- ---------------------------------- ----- ------------------------------------------------- - - and/or Contractor) -By: - ., r — - - -------- ........-- - --=--- -- -- � _ X_ t. (Title]: -.. - (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse��side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- . ---------- ----- --------------- BATE I REVIEWED BY------ --------------------------_--- - - ---- --------------------------------------------------------------------------- DATE----- �� ------------------ BUILDING PERMIT ISSUED-------- -- ------ --------------------------------------------------- - - ------------ -----------_ DATE------------------------- �M ----------------- Alterations and/or recommendations:_.._._.-... ............ IM -------- --------------------- ----------------------------------- ------------------------------------------------------------- --------------------------------- ---- = ---------- ----------------------- ----------------- ----------------- --------------------- - --- -------------------------------------------------------------------- --------I-M---------------------------------- ------------- I� . I ----------------------- FINAL INSPECTION BY:. ------ --------- Date-- ~- -� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 20.5 West 9th Street , Lodi. California MantecaCalifornia Stockton,California Tracy,California E.H.9 2M 1-67 Vanguard Press