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FOR OFFICE USE: -_ ---_--------- f ---_--_ APPLICATION FOR SANITATION PERMIT Permit No. ..!__�P_ 7�-- / _,.____�_____________ (Complete. w ---------------------- ----, _- ,._. —�. -� Date 1'ssued ---- --/ -.�3 �- —}-- -i=� '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. J { JOB ADDRESS AND O AT =---: _-, _� ` Owner's Name----------- 1� - .r Phone--:--: ---------- 4Address ' . - ---------•-------•-- �---- ---------------------------------- Contractor s Name._ t-------- ---------------------------------- ;_ Phone Installationwill serve: ,Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El i Number of living units:,__ --;Number of bedrooms A- Number of baths _/__ Lot size _ ----------------------------- 1 Wafer Supply: Public system *11�Community system ElPrivate E] Depth to Water Table Character o-soil-toapdepth-of-34f et: ' Sand ❑ Gravel ❑ Sbndy Loam ❑ Clay Loam ❑ Clay Adobe hardpan ❑ Previous Application Made: (If yes,date--------- -----------) No New Construction: Yes ❑ No [&r-FHA/VA: Yes ❑ No 0— TYPE OF INSTALLATION AND SPECIFICATIONS: t (No aseptic tank or cesspool perrnitfed if public sewer is a Table within 200 feet.) Septic.Tank:1. 1 } nie nearest well. 'Distance from foundation------------------ Material----------------_--------------- = ------_. � � Docompartments --------------- Z Liquidpf --------------------------Capacity Disposal Fi`Id: Distance from nearest well---- Distance-from-foundation.�_/R- _--Distance to,..nearest lot line--- N .____..... Number of lines-__._____ _,_/ --- -_-____Length of each line____I?"Q-�__-_-� Width of trench__,r�_.�_____________________ / pp Type of filter material _�_!f-��i.r'Depth of filter material_____/-_�__--.-.--Total length- _��---------------------------- Seepage t: Distance to nearest well------ �.__._�Distance fr rn foundation-__-� Distance to nearest lot liline_________________ �i Number of pits...--------------Lining material_ il_.Size: Diameter..'-_-__-_._____D pth,S Cesspool: Distance from nearest well---------------6stance from foundation--------------------Lining material--_------_-_---------------------- ❑ Size: Diameter------------------------------------`Depth -------------------- Liquid Capacity = gals. Privy: Distant from nearest well----------------F----- -------------------------Distance from-nearest building_�_--_-_--------_---___-----_-_______._. ❑ Distance to nearest loft line-------------------------- ---------- ------- ------------------------- -----------------------------.� J Remodeling and/or re �.iing (describe):--------- ------�I ---_:._ - -��- -----------------?!7--- _ '------------------------------------------------------------------------------------------------------------------- ------------------------------------ ------------------------ ' f ------------ I hereby certify fhat�l-have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, andirules and regulations of thp San Joaquin Local Health District. (Signed) - ------------- ------ --------------- ----- - r Contractor) - ._Title _%��.F_ Br•-!-------------------------•--•--•--------------------------- ................ ----- (Title) plan,ishowing size of lot, location of system in relafi o wells, buildings, etc., can be placed on reverse side). FOR EPARTMENT USE ONLYen ; APPLICATION ACCEPTED BY--------`----=--------------- - -------------------------------------------------- DATE---------I --------------- ----------------------- REVIEWEDBY----------------------------------------------------------------- -- - ------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED--------------I-------------- ---------- ---------------. DATE--- - ----------- Alterations and/or recommendations--_,_-.---- '- -. �?_��_______ _________D� ___ .- -_1_� --------•------- �i - --------------------------M-M------- --------------• -------------- -------•------------ ------------------------------------------------------------------------ ------------------------ -------------------•----•----•--•----------- --------------------------•----- ----- ------------------- ------•- ----------------------------- ---------------------------- ---------------------------- --------------------------=----------------- FINAL INSPECTION BY:----- t ------ --------- --- - -- --------- Date--------- ----- P E �� t J- �I ,SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Noxellon Ave. 304 West-Oak-Stre'et 124'SyceZare Street 205 West 91h Street Slocklon,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.54 3M 3-'63 F.P.CC.