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Permit No. APPLICATION FOR SANITATION PERMIT ._� 77 .. (Complete in Duplicate) p + ILAe Date IssuedyY4 r 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. JOB ADDRESS AND LOCATION.... '� _' "f�' r�---- I. Owner's Name-----------------------------------:P�--- ------ ------------------ - ------------------------ -------- Phone--- P_ •-.-------- aAddress ' ------- ------ ---------- ..---•--------------------•--- - -------------- -- --------- ------ -- - - Contractor's Name-------•------------------- i _k_f • -- ¢ --------------- Phone 'r 4 Installation will serve: Residence D( Apartment House ❑ Commercial ❑ Trailer Court t] Motel ❑ Other ❑ Number of living units: I----- Number of bedrooms __-Number of baths'_____ Lot size �.�'___�A._l�P_�________________-__ Wafter- Supply: Public system El Community system El Private X Depth to Water Table�_�_: ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ • Clay Loam ❑ Clay ❑ Adobe U?P0 Hardpan ❑ Previous Application Made: Yes ❑ No,E�r, New Construction Yes E] No ❑C 1Z�_—�t�'-c" , TYPE OF INSTALLATION AND SPECIFICATIONS: 6 ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ,Septic,T nkE Distance from nearest well-----------------Distance from foundation--------------------Material_______________.__.___________-__._-.:__________- No. of compartments----=---------------------Size--------------------------------Liquid depth--------------------------Capacity---------------•------- �isposaal Fielo- Distance from nearest well__---------------Distance from foundation-------------------Distance to nearest lot line____________..... o , yG!� Number of lines-----------------------------------Length of each line------------------------------Width of trench-_-,------------------------------- -aType of filter material___-_____._____._______Depth of filter material-----------------------Total length__-_.________________________-_____--____ Seepage Pit: Distance to nearest well Q ______-_Distance from �ff,o��ndation___l_Q_�____.Distance to nearest lot line___= Number of pits.-_-_.�______________Lining material_ y�____Size: Diameter____�"`______.Depth____r�;�=_ Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining ❑ ma#erial'_�__4____________________.... _--Size: Diameter_---------------------- -------------Depth-------------------------------------------------- Li Liquid Capacity gals. Vy Privy: Distance from nearest Well---------------------------------_---------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line---------------------- ------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)�-------------------------------------------------------------------------------•---•----------------------------------------------------------•-------• 1 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------•----------- ---------------------------•-----••-------------------------------------------------- -------------------------------------- --------------------------------------------------------------------- --------------------------- ----------------------------------------------------------------------------------------------------------------------------------------•--------------•---------------- I hereby certify th t I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stare laws, nd r es--id-regulations of the San Joaquin Local Health District. Si ned ( g }-------------------------------------- ---- �--�'.�.--"i------------ --- - - ------------------------------------------------------_.------- dor Contractor) (flwn�aad' �, - BY �` - -- (Title} -`- -------------------- (Plot plan, showin4�f-lot, location of"system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 5 APPLICATION ACCEPTED BY -- -- DATE / - i' °`- ? REVIEWEDBY--------------------------------------------- --------- - --------- ------------------------------------------------------- DATE - - ----- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:----------.---- --- ---- ------------- ------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------ + ----------------------------------------------------------------------------------------------------- --------- -------�i�/ ' - ------ ----------- ------------------------------------------------------- ------------------------- FINAL INSPECTION BY:--------- Daie---- --------------------,--- --•- F l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Sfockfon, California Lodi, California Manteca, California Tracy, California 1 I ES-9-2M 8-51 Revised W-2100