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APPLICATION FOR SANITATION PERMIT permit No. ?r {Complete in.Duplicate} 7 Date Issued -{o•��_ —S Application is hereby made to the San Joaquin Local Health District fora r This application is made in compliance with County Ordinance No. 549. to con t, tat! he c ork herein described. y JOB ADD ESS AND LOCATION.",. �� J � Owner's ame--,1�--- - -- � -' - •---� - ------� .�-----•-----��U�y.f��,/� 4/ y`-�' --- ------ - - Address ------ A ----- Phone- - _• -•,,,�•------- ----- Contractor's Name--- I I `' Installation will serve: Residence ` - Phone__ - - partrnent House -0� ❑ Commercial ❑ Trailer Court ❑ Motel Number of living units: --/-- Number of bedrooms _ ❑ Other ❑ ~ - Number of baths ---/--- Lot size ---_ Water :Supply•,' Public system ❑ Community system Character of soil to a depth of 3 feet: Sand ` ❑ private �epth to Water Table _f_o ft. Previous Application Made: Yes ❑ Gravel ❑ Sandy Loam ❑ ClayLoam f ' I ❑ Clay ❑ Adobe lardpan ❑ TYPE OF INSTALLATION 'AND SPECIFICATIONS:Construction: Yes �Na ❑ h (No septic tank or cesspool permitted if public sewer is available within 200 feet.) IF �SS Septic Tank: Distance from nearest well---�-Q i Distance from foundation----- ` i No. of-compartments----- -----.Material--- ---Size--s `'�/.x_____3___ Disposal Field: Distance.from nearest well_ �' Llqu�d depth----y- f---Ca acct -- d --Dis+ante from foundation p YQ O - e Number of lines---------- Distance to nearest lot line---_c -�__•__ - �- .- Length of each line______---_ --' Type of filter material----tom 9��-----------.Width of trench-.im_(�-`! 'l� DepttZ of filter material--_-_;l -!' -- _ ----Total length- -•---- Seepage pit: Du ante to nearest well---- g 1�0--------___ -- -- :_-___Distance from foundation-------------------- ❑ Number of pits---------------------'Lining material------ Distance to nearest lot line--._--____------- Cess Cesspool: ' --------Size: Diameter_-_---__.___- p Distance from nearest we --------Depth------------------------ --__Distance from foundation- _-- -----Lining material------------------- - i Size: Diameter--------------------=-------- .S Depth ------------- ------------- ---------Liquid Capacity---------------- ----------gats. privy: � Distance from nearest well _ ----------- -- - Distance from nearest building Distance to nearest'lot,line'-. ::--_---_ g------------------- ----------------- -- ------------------- Remodeling and/or repairing (describe): ----------------------------------------------------- ------------------•- ----------- --------------_- -•--------•---------------------------------•-----•-• ------- ---- ------------------------"'----------------h------ * 4 -----------`------------.-_._--_--_--_.-•----.---_--- -___-•-_•-____-__•__•-------_--•--___•-------------•-•_-••_--__•_--_--•__•__-•---___--•----_-_---_------_.--_----_--__----- -•----•-•-•-------•--_--___ - - --• - I hereby certify that I have prepared this application and that;the work will be done.in accordance with San Joa u-n Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ' q Y (Signed) f �-"��f---_- By:--------- - --- or Contract r - -- -------------------------- -- ---- (Title)----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---___-.- _ REVIEWED BY. ---------- DATE--_-- ---------- ----- f ------------ BUILDING PERMIT ISSUED } DATE - -------------• - -- r - ----------------------------- erations and/or BY DATE-----------•-- ----- ---------- ------•.._ --------- FINAL INSPECTION BY:: -_ �' S Date ------------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street Stock+an, California 132 sycamore Street 814 North "C" Stree+ Lodi, California Manteca, California Tracy, California —9 2M 10-s2 Rev;sed W-2100 4