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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 Date Issued ___ �_6- ------ _� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein d scribed. This application is made in compliance with County Ordinance No. 549. 2, JOB ADDRESS AND ION-----P ---1-26--11/7 17 r Owner's Name----- L-t2,r., ------------ -- ----- - -- -- ------------------------------ Phone- O-T-•--1-17- ----------------------------------- Addr • - Addre r------ .............. y Contractor's Name------------------- ------- --- •--- - C] t Phone Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ k Number of living units. _Number of bedrooms _ _ Number of baths .__ of size ------------------------- ------- Wafer Supply: Public system ❑ Community system ❑ Private ❑ Depth to ater Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam V Clay Loam ❑ Clay ❑ Adobe❑ Hardpan [❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes No ❑ FHA/VA; Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic sewer is available within 240 feet.) Septic Tank: Distance from nearest well' J9_�__..__Distanc` from foundation----�_.p........M _r-�__ ____r. �______ __ C- No. o€ compartments------ _r Size_ _ ./!-__x��___Liquid cl�th--- ._.____Capacity__�. f�_.___ Disposal Field: Distance from nearest well__..._Distance from foundation-_49..........Distance to nearest lot line----------- t Number of lines_____ _____ _ Length of each line---,r__Q_. .__ _____.Width of french-cA_el._�� Type of filter material_ _._ f _.Total len th________ �1 C7 �� (_Depth of filter material-------- _ g "T ______________ (14 Seepage Pit: Distance to nearest wet!----------------------Distance from foundation--------------------Distance to nearest lot line--.-- ___.__--_ ❑ Number of pits______________________Lining material-----------------------Size: Diameter.----------------------Depth______________________.________ Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material-_._._______________________________ ❑ P --------------------Liquid Capacity----------------------------gals. Size: Diameter------ ------------------------------De th---•--------------------- ------ Privy: Distance from nearest well--------------_---__-----------------------------Distance from nearest building----------------------------------------.. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------- ----------------------------------------------- Remo eiing and/or repairin (describe:_____ _ _ __ ___ �_______________________ ------ --- - - -- --- ------- - ------- - - ------ - ----------- -----------Lreby------------------------------------------------------------------------------------------------------------------------------------------- -- ------ - - ---- ---- --- I certify that I h ve prepared this application and that the work will be done in accordance with San Joaquin County , ordinances, a and ru aqd re tions of the San a in Local Health District. i \\ �_ fir, 1 (Signed) ku �'� �-----�L---1 f- ---� l -------------------------------------------- d/ Contractor) By:------------------------------------•-----••-----•------------------------------------ --- - - _- - -----------(Title)-------------------------------------- ----- _- ! (Plat plan, showing size of lot, location of system in relatio o wells, buildings, tc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------- ----- ---------------------------------------------------- - -- REVIEWED BY--------------------------------------------- ------------------------------------------------------------------- -- -------- DATE--------------------------------------------- • • - BUILDINGPERMIT ISSUED--•--------- •--------------------------------------------------------------------------------------- DATE--------------- ----- Alterationsand/or recommendations-----------------------------------------------------------------------------------------------------------------------•--------------------------------------- - •- ---------- ------------ ------------------ ---•--- --------- - -------------------------------------- -- ----- ------ ----•--- -- ------------------------•--••---------•------------• ------------------------------- --------------------------------- ----- -------- -------- - ------�.. -------- ____________________________________ _________________________________ ______._..._______ __.__ _ ___ _ ---------- __..._______......__._ - ___.-R.-___------.._____.____._________ FINAL INSPECTION BY------------ ---- ---- -- __ - Date--------_ __- - _-- - T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nazolton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 5lockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED B-59 3M 3-'63 F.P.CC.