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i APPLICATION FOR SANITATION PERMIT Permit No. _...: . (Complete in Duplicate) / Date Issued ._- This Permit Expires 1 Year From Date Issued - -- _�/ -ID 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. V_jJOB ADDRESS ANC?"LOCATION---nwv,�wld`�Z , t ..� - '?' _... � - • V Owner's Name---------------------- -��...... Phone----..---.....-.- .---•---•---•---- Contractor's Name------------------------------ �� - �" ---4-0hone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ MVfaijj Other p Number of living units:--:-t- Number of bedrooms -,3--- Number of baths - Lot size _---- __J' ----------------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -_ ---- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes [] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPEC IF.ICATIONS: (No septic tank orcesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well-----------------Distance from foundation--------------.--__.Material---------.-:------.------------.----------------. Novfcompartments------------------------Size----.-.--------•------- ---•--Liquid depth--------------------------Capacity-----------•---r----•- i Disposal Field: Distance from nearest well..5_0.......Distance from foundafion.,141,Pf?!?e -.Distance to nearest lot line__--�-.. 0 1. Number of lines-------- -------- --- - - Length of each line__5- --------------------Width of trench-..- _ -'�_______--_-___ 'Type of'fifter matenial,_,�i :_Depth of filter material-----/r.........Total length------J_:5_6-------------------- Seepage Pit: Distanc.b to nearestU lI----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number o`,pits----------)---.-----Lining material-----------------------Size: Diameter-----------------------Depth---------------_--------_-------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------.__-------. ❑ Size: Diameter14"----`-- -----.Depth---------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest III---- ------------------------------------------Distance from nearest bui0ng-________-.----------------_----.-.------. ❑ Pistance,to.nearest lot line---`=--------------------------- --------------------------•- •----•------------------------------------------- r -- - ----- --- --------------------- - ------------------ j - - - - ---- ---- - ---------------------- -- --------- =--------------------------=----------------------- --------------- -------------------------------- --------------------------------------------- I hereby certify that I have prepared this application and that the work will.6erdone in accordance with San Joaquin County ordinances, at law nd" es a ' regulations of,the San Joaquin local Health District. (Signed)-/r1------------- --------- - ------------------------------------------------------------------- ----------------------------------,----- ( / _Owner and/or Contractor a By. .:............... (Title) (Plot plan, showing size of lot, location of system in relation to wells, build ings,`etc.. can be placed on reverse side). F R ME USE ON APPLICATION ACCEPTED BY--- -- 44�-- - ATE--- ----- ----� -41�-/ ----------------- REVIEWEDBY--------------------------------- ---------- ----------------- ------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------- -----. DATE------------------------------------------------------------- Alterations and/or recommendations--------------------------------------- ------ ------ ----------------------------------------•-• ------------------------------------------------------- -------------------------------•--------•--------- ------ ----------------- ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------- •------------------------------------------------- --------------------------------------------------------------------------------------- ----------------------------------- -------------------------- ------------------------------------------------- ------ -------- ----------------------- ---- ------------ - - ------- -- -------- FINAL INSPECTION BY:.- --------------------------- Date. �'��' y---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street a 132 Sycamore Street 814 North "C" Street Sfockton, California Lodi, California Manteca, California Tracy, California e ES-9--2M Revised S-'59 F.P.Co. , p