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APPLICATION, FOR SANITATION PERMIT Permit No. ...�z (Complete in Duplicate• bate Issued ._.._____.�.__, , This Permit Expires 1 Year From Date Issued 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. A040—JOB ADDRESS AND LOCATI N___-- --)---- __,F _��)? �------- ------ •--- Address_Name---• ---- -!-- a-� -------- --------------------------- -------------- ---------------- Phone. Owner's Name Address--_---------------------- wner s - --- ---- Contractor's Name----------------------------- Phone_...--___-.---------...---_----•- - -- --- ------------ Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ O er [I a x -� Number of living units: __1___ Number of b'edroom s _1--- Number of,baths J___ Lot size Water Supply: Public'system ❑ Community system ❑ Private W`-'Depth to Water Table IZA ft. Character of soil-to a depth of 3 feet: Sand ® Gravel El Sandy Loam El Clay Loam ❑ Clay ❑ Adobe C] Hardpan ❑ Previous Application Made: Yes ❑ No ❑, New Construction: Yes ❑ No ❑ FHANA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet) 1 Septic Tank: Distance from nearest well-,725__---__Distance from foundation__1_P.______.__.Mat ria4__ _ _ .___.___.-__ i 3--x Q ----Liquid depth----- - Capacity..__- Q--------- No. of compartments----- ----------•-Size--- r Disp sal Field: Distance from nearest well..4-4--------Distance from foundation.- rl.I------- Distance to nearest .ot41}-�e_ ---'I^"r""� • Width of trench----- 41- Number o£ lines---•------ --------� -- �,9 t - ---- �-�___.__.--- Len th of each line__-_______ _-+�- -----. r- Type of filter mater-i-a _ __ epth'of�flter mafterial___._�_ ______-f---Total length_______. _-- Seepage Pit: Distance to nearest well_______---____-___Distance from foundation--------------------Distance to nearest lot line-_-______-_____. ❑ Number of pits--------------------I Lining material-----------------------Size: Diameter.----------------------Depth--------------------------------- Cesspool: Distance from nearest well----------------Distance from foundation------------.-------Lining material------------------------------------- ❑ Size; Diameter-------------------J_--------------❑ e�D ----------Liquid Capacity--------------------------- Privy: Distance from nearest weR________.--__________--__-____r-7— -""-_D1s'tance`from nearest building_____________________ 1 ❑ --- Distance to nearest lot line --------------------------- - -- •-----------------•----•--•---------------------------------------------------------------- Remodeling and/or repairing (describe)-------------------------------------- ( --......... --------------------------------- ----------------------------------------- •-----••------ t ------------------------------------------ -- --------------------------------------------- -------------------- ----- ----------- ----- ---- -- - -------•---------------------------- ----�---------- -------------------------------------------------- I hereby certify that I have prepared this application and tha#the work will be done in accordance with San Joaquin County ordinances, State laws, aA rules and regulations of the San Joaquin Local Health District. „ T (Owner and/or Con#ractorl (Signed)---- --- --- - ----6vp-�,-�-f>� .��•'---------- ------------ ----- ----- - ---------------------------------------------------------- - ---- - -- -------------------- I_La----------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.,}awn be placed on reverse side). FOR DEPARTMENT USE ONLY w , APPLICATION ACCEPTED BY------ _________ DATE_,___. f f------------ REVIEWEDBY------------------------------------- DATES`--,,-----------------------------------------•------- BUILDINGPERMIT ISSUED----------------------------- ------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations------------------- -------------- ----------- -------•-------------------------•-------------------- ------•--•--------------------------------------------- --- --------------------------------- -- ----------------------------------- ------- -------- --- ------------------ --------------------------------------------- -•------------------- /17 _ FINAL INSPECTION BY:---- ...... Date. � �� f_� ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" street 130 South American Street 300 West Oak Street � Man+eco, California Tracy, California S+oek+an, California Lodi, California FS-9-2M Revised 8-'59 FY Co. -