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APPLICATION FOR SANITATION PERMIT Permit No. .-- -------------- t/ j i (Complete in Duplicate) r { Date Issued _�- -/_.� - _3 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 LOCA ION. -- v , ----Avee RE-''I l-'0 Owner's Name = "Y` + Address.------•------- ---- ---�--- - ----------- Phone d ---------------------- ------------------------- ------•-----•--------•------------------- Contractor's Name----------------------------- _ - ---._ -•------------------------ --- Installation will serve: Residence Apartment House ❑ Commercial Phone-------------------- Number of livin: units: _ ❑ Trailer Court ❑ M�t�f ❑ Other r g ---- Number of bedrooms _ -`- Number of baths -_(--- Lot size 's ❑ f Wafer Supply: Publics stem --�•----- - Y ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand El Gravel I-] SandyL - Yoam ❑ Gay Loam ❑ Clay4 Previous Application Made: Yes No ❑ Adobe❑ Hardpan [] ❑ ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T,ankk: t Di ante from nearest welt__----_--_--__Distance from foundation--------- El I- ��. f compartments- ---- Size Material----- I t Liquid depth--------------------------Capacity----------------------- or Disposal Field: Distance from nearest well-__�-� ----------- ' ------Distance from foundation---_- - --_ �� ---. Distance to nearest lot Ike--��--_-_-- ® Number of lines-----------�:•_ Length of each line - j ��-----.Width of french---- Type Y�- Type of filter material ,__ - -- - - Depth of filter material--_- -� - Total length �Z Seepage Pit: Distance to nearest well...---____-__-------Distance from foundation--._ Distance to nearest lot line----------------- Cesspool: ----------------� ❑ Number of pits----------------------Lining material--- I • _.-_---Size: Diameter-------------- Cess ool: - --- �--..Depth------------ ----- ❑P Distance from nearest well-----------------Distance from foundafion.-. --------------- Lining material-._-----_----.--__ Size: Diameter Depth------- - --- - ------ -------------- '-_-Liquid Liquid Capacity- ----------------------- Y� Distance from nearest well._-_-__--_---_---_- --gats. ❑ 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 Joa uin County ordinances, ;Sffaffe la s, and rules and regulation the San Joaquin Local Health District, q (Signed) ---- = ? e $y:-------- --------••----------------------------------------------------- f -----'-•------•---------- -- - and/or Contract (Owner / or) i -----------------------------------------•---- ----------(Title)---- -- d o (Plot plan, showing size f lot location of system in relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ -- -- ---- --[' REVIEWED BY_. ---------------------------------------------- ---- DATE------- r BUILDING PERMIT ISSUED------•------•-- _ -- -- --- -------- ------ ---------- ---- ---------- ----------- DATE------------ f A terafions and/or recommendations -:---.-------------------------------------------------- ---- ----------- DATE-_---�-- -� ----------------------------------------------- _------- ----- ------ -------•-------•-------•------------------------------- ---------------•----•-------------------------------- ------- ------------------ v �---- _- - -------- - T _ ----------------------------------------------•----------------------- ------ ------------------------ -- I ------ ----- •------------------------------------------ FINAL INSPECTION BY:------ _4 ------ ------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes} Oak Sfree+ S+ac(<+o n, California 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California Es-4-2M 10-52 Revised W-2100