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FOR OFFICE} (/ -- ... ............................... ..-- APPLICATION FOR SANITATION PERMIT Permit No, --- .. ................... . .. ----- ------ .............. (Complete in Duplicate) �a This Permit Expires 1 Year From Date Issued Date Issued ......... .... ..�.. Application is hereby made to the Jen Joaquin Local Health District for a permit to construct and instaA the work herein described. This application is made in C�Nl mpliance with County Ordinance No. 549. 1,31 - �-� JOB ADDRESS AND LOCu Pi.W1a �c ..on ;1-g------ °......cit-y3-•------.JoC -- Owner's Name---NA-...................................... -------------...........------------------- ----- ...-- -..................... Phone.----------.----------.._... Address............----N11--c�i? -:........ ............... -----------------...................................................-----I...............-------...........i�;.. Contractor's Name... .................7' . .........................................................---------------------------- Phone........`f-5.._�- - Installation will serve: Residence ❑ Apartment House ❑ Commercial E� Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A.- Number of bedrooms Number of baths Z... Lot size ..8°.X Z`0 ------------------------------------ Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Table IP-.- ft. Character of soil to a depth of 3 feet: Sand ❑ Grovel ❑ Sandy Loam(3—Clay Loam ❑ Clay ❑ Adobe❑ Hardpan❑ Previous Application Made: (If yes,date....................I No 0---New Construction: Yes ❑ No ty—FHA/VA: Yes ❑ No 2— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) nc` Septic Tank: Distance from nearest well.$V..........Distance from foundation...l�.............Materiel.. P.,.'....._.....�9!t... No. of compartments.......P..._........._Size._ -r?X.`2#'!�.....-Liquid depth....S'...`_..-_---------Capacity...1..24�.�. , t Disposal Field: Distance from nearest well._ A.......-..Distance from foundation.l-Q..............Distance to nearest lot line.'.......... ENumber of lines........ .....................Length of each line.....$ ....................Width of trench.._-X'y........................ Type of filter material-`loc-A---.....Depth of filter material..Jk."...........Total length..._ E°.. ......................... Seepage Pit: Distance to nearest well__. ----------------Distance from foundation..-...............Distance to nearest lot line................. ❑ Number of pits......................Lining material-----------------.-----Size: Diameter.......................Depth--------------------------------- 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----------- ------------------------._.. ❑ Distance to nearest lot line-------------- .......................-- -- --.---------..--------.............._..._.......... -- . ----------------------------- Remodeling -- ------- Remodeling and/or repairing (describe):............................... ......................................---....................................---------------------------------- ------------------------------ - ------ ---...-.-------........................................-------------------- ------------------------------------------------- -------•........._....-----....... --------------------------------- .....................---- ------ ...............-----------------------------------------------------------------------------------------------------------------............ I hereby certify that I have pre)r red is applica on and +hat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an regu 'ons oft San Joaquin Local Health Disfrict (Signed)....---................---......•-----------. ....... ... . --------------- ------------------ --------...-------------------------(Owner and/or Contractor) By:..... -- ......... -t..._._.------------ - - - ..(Title)---------._------------ ------------.._._.._... .. .... (Plot plan, showing sise of I , Ib ocati n o system in relation to wells, buildings, etc., can be placed on reverse side). R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.......... ....... ........../ 7- - ---------------------------------- DATE. .... - REVIEWEDBY......................................................--------------- --------------- -----------.......................... DATE---------------------------------------- --------------- BUILDINGPERMIT ISSUED................................................. ..... ..--------------------- DATE----------.....------------------- -------------------- Altera+ion;ander recommendations:T .................................... -----------------------------------------...----------------------------......----------------------------------- ........10....lL. ..Lr..L.._c.........! ...... -------.------------------.--------------------------------------------------------------------------------------------------------- .. ......................--.....................................................................................................................................................................................I.............. .........................................................................................................................--................................................................................................. FINAL INSPECTION BY:-...... l-''!"�a� a - Date----_ --- --�� /r/ " s� -- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American strut 300 West Oak Strati 124 Sycarnore Street 205 West 9th Serest St"Mon,California Lodi,California Monism,California Tracy,California E9 9 BEME0 B•59 2M 5.62 ATLAS