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FOR OFFICE USE: -------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. / --------------------------------------------------- 4 {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 cons ucYsaeh all the work herein described. This application is made in compliance with C my Ordinance No. 549. JOB ADDRESS AND LOCATION---- -----=-----' -------------- --- -_ n - ---•---- -------...-•------------ Owner's Name--- i j � y�[ ------ --- - --------- Phone Address------------------ ig..... Contractor's Name t--- =- Phone----------------------------------- Installation will serve: Residence ❑ .Apar ant House ❑ Commercial ❑ Trailer Court ❑ Motel [] Otherr�.� 1 Number of living units: __'___ Number of bedrooms eZ__ Number of baths -_-_ Lot size __ _____________________________ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table _4+7ft. Character of soil to a depth of 3 feet; Sand ❑ Grave! ❑ Sandy Loam ❑ Clay Loam ) Clay C] Adobe ❑ . Hardpan, Previous Application Made: Ilf yes,date------------ l No New Construction: YesA . No ❑ FHA/VA: Yes ❑ No ❑ TYPEOFINSTALLATION'AND SPECIFICATIONS: �] _*(No septic,tank-or cesspool permitted.-if public.sewer`•is available within 200 feet.)•,,. _ Septic Ta Distance from nearest well___©___.:Disfance frorr, foundation____/Ig_._.__._.Materrial-_ _ __�C7'�'p_,_Citv--- Dis ._....__.__-__.No. of'compartmen4ts_''�r ._:__ :--_Size__, _•#_` _ .1 ___-___Liquid depth_____`, ____...___..- _. 4posal F' Id: Distance from�neek;st well__ S_�.� Distance from foundation__, Q_--_______Distance to nearest lot tin e__--_-.- -�-- Y ` Y A`1 --- -- . LLLJJJ Number of lines______________ _________ _________Length of each line___ --_ -_0..Width of fren6.___.2------------ Type Type of,filter mater.ia'I. ,_ :.________._Depth'of filter material-__�_�_..._______..Total length___.____- +_11r, >.. } See age Pit: Distance to nearest wail----/_______Distance from foundation----/a-_______.Distance to nearest lo# lin Sf________ .y Number of pts--- ------------- --Lining material-, -------Size: Diameter--.- --, - -------Depth___ ---- ---------------- ft 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____.__._____________________.__________. .f ❑ Distance to nearest lot line-- ----------- -------------------------------------- ---------------------------------------------------------------------------------- r 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 oaquin Local Health District. (Signed)------------ ---- - - ------- --- ------ -------- -------------------------(Owner and/or Contractor) lop _.- B : - =1i/ - --------=- ----------------------------- - -Title------------------------ -._,.:._.... — (Plot plan, showing size of lot, location of;sys+em in relation to wells, buildings, etc., can be placed on reve6side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ---------------------------=-------------------- DATE---- Z -------=--=-------- REVIEWEDBY---------i--------------------------------------------------------------------------------------------------=--------------- DATE-------------------------------------------- BUILDING PERMIT ISSUED ---'------------ - DATE ---------------------- Alterations and/or recommendations:----------- ------------- ---- -- ---- -- - ----------------------------------- ----------------------------------------•-•-------------------------------- t # -------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- --------------m----------------------------- ----------------------•----------------------------- -------------------------------- ------------ --------- -------------------- -----------------------------------------•-------- ------------------------------------ ------------ ------- ------ -•---------- --------•--------I------------------------------------- FINAL INSPECTION BY: °il ? -r �Date__�� T `� U +�# '� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.4laxeilon Ave. 300 West Oak Street 124 Sycamore Street _ 205 West 9th Street Stocklonr California Lodi,California Manteca,California Tracy,California ES 9 REVISED 9-59 3M 3-'63 F.F.CC. r