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APPLICATION FOR SANITATION PERMIT Permit No. .... la.... (Complete in Duplicate) y Date ISSUEd Applica{ion 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::. _ -_-.-4________"_`.___ .. . - Owners Name_.,._ _ =-Q_� 1tJ�. � ':- J_ "= -------------------------------------- � w --•---- -----------------•-----f•-------•----- �-�.`�`'"�-- ----`-- -�---- - Phone-- �-;-'-v-�!*--r-------------- r �--.� Address........... �'� / ----------- ---- -� _ 1 Contractor's Name. ` - -------------------------------- ------- Phone----------------------------------- Installation will serve: Residence ° Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ____ Number of bedrooms __umber of baths ----[-__ Lot size -------- ._ � _— ,__.<________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �� Hardpan ❑ Previous Application Made: Yes E] No New Construction:.Yes 'No [ TYPE OF INSTALLATION AND SPECIFICATIONS: ✓ (No �j septic tank or cesspool permitted if public sewer is available within�200 feet.) - ' T, _ Distance from nearest well__ --------------Distance from foundation__ -------------...Material__.____-____-__-_ Sept{ - �[, No. of compartments------ -------------------Size------------_---------------------Liquid depth--------------------------Capacity------- --------------- L g Distance from foundation_._ .0 -------Distance to nearest !o} line___1t- ______i Number of lines-------------- '� Disposal Fielci: Distance from nearest well.----. �___ ength of each line___-____�___�.___ __�,eWidth of trench_.._._ "" � 11 /� ------------------ To e of filter material__..4.�. -�'Qepth of filter material....____ _____Total length_______. ___� ____________� 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...----- :---------- --------------Li uid,Capacit ........ -----------------_gals... ' Privy; Distance from nearest well------_---_--------------------------------------Distance from nearest building_-_____-__.___._______________.__..__.-_-. [) Distance to nearest lot line-------- -------------------------------------------------------------------=------------------------------------------------- Remodeling and/or repairing (describe) ----------------------------.------------------------------------------------_----------------- ---- ------------------------------------------------------------------------•••-----------------------------------•-----••-------•------------------------------------------------------------------------------------------------ - --------•------- -----•------- ------------------------------------•-•------------ ••------------------------------ -- --- - ---------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San J aquin Local Health District. t (Signed) _______________ _- ^++e�� ___ ._ _ _ Owner and/or Contractor By:------------------------------- -------------------(Title)------------•--------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------- ,--_/._,. - lL--- -------- -------- DATE-------- y-------------A---------- REVIEWED BY------------------------------- ----- ---- - -------- DATE--.- -- -------- ---, , 7 BUILDINGPERMIT ISSUED.-----•------------------------------ - -------------- ----------------------------------------------- DATE--------- --`---- Alterations and/or recommendations:.......... ---------------------------------------------------------------•-------•----------------------------------------- ----------------------------------------------.-------------------•-- ------ -------------------------------------------------------------- ----- ---- ------------------------------ -------------------•-•---------- -----•--•------- - -------- ------------------- ----- -- •---•------•- -------------------------------------------------------- FINAL INSPECTION BY: ---- --- -------------- Dafie. _.._..... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C" Street Sfockfon, California Lodi, California Manteca, California Tracy, California ES-4-2M 145446 ATWP4o 12-54