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i APPLICATION FOR SANITATION PERMIT Permit No. ...f--- ___ ------ (Complete in Duplicate) 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. JOB ADDRESS AND //LOCATION-- ---- ------ -- -- --- C__D -_ ----_----- --------------- _tO� _ Owner's Name---------V -- _ •------ ---- Phone__) �_/_ /----.--- Address........---------------.�. _a--- -- -- ----- -- - ------ --------- -------------------------------------------------------------------------------------------------- Contractor's Name --r!l� 2"�r'�/ Phone -'7A-Q- ------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J--- Number of bedrooms __-_t_ Number of baths .-/___ Lot size -___?_4_--C - -..___------------------------ Water _____________ _________Water Supply: Public system ❑ Community system ❑ Private �pth to Water Table _10 ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2-_"H�ardpan ❑ Previous Application Made: Yes Jo New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No sepfic tank or cesspool permitted if public sewer is available within 200 feet.) , Septic nk: Distance from nearest well- -O--r Distance�from�foundation---./_Q----------Material--- �a___ __ ______ ________ No. of compartments p �- SizEA._ -- -- -. Liquid depth-----��-------------Capacity__. dp-' ________________ x rt -- --- / Disposal Distance from nearest welLl/�__.__Distance from undation__ __________.Distance to nearest lot line____-_ f____ Q� Number of lines______________ Length of each line--------a _t_________.Width of trench---- __y"-_---_----_-_-_ ` t'1-,,-� Type of filter materiall/A_-- --�-----_Depth of filter material-------- y Total length-----=_d_f___..___________________ SeepagPit: Distance to nearest well _��--QDistancefro�I fouQdation--- d_____._. Distance to nearest lot line_��-_ Number of pits_________ ___________Lining material C�l. _Size: Diameter____.- k______..Dept h---o.1-J---------------- ------ Cesspool: Distance from nearest well-----------------Distance from foundation____________________Lining material-------------------------------------- El Size: Diameter------------------------------------.-Depth-.---------------- ----- ----------------- Liquid Capacity-.--------------------------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 Joaquin Local Health District. s (Signed)------- ----- -------------------------------------------------------------------------------•------ ---------f1pomw and/or Contractor) B --- ------------------ ------------------------- ----------------.Title Y• ..__... ( )-- ----- ----------------------------- - (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--------------- -- --- - ------------------------------------------------------------ DATE--- -•--- -- -- ----- �--- REVIEWED BY---------- - --- - ---=------------------------------------------------- DATE-- ---- -- - ... BUILDING PERMIT ISSUED---------- ---------- --------- ----•-• ----------------------------------------------------------- DATE------------------------- 4, Alterationsand/or recommendations:----------------------------- -- -------------- ................__..............................0------------------------------•----•----------------------- --------------------------------------------------------------- -------------------------------------------------------------------------•----------•---------••-•------------------------------------------------------------- -------------------------------------------------------------•-- ---------- ------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- ----------• •-------- - -----------------------------------------------•------------- FINAL INSPECTION BY:.._.___-__-Y-._.. y -- /-- ------------------ Date------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streef 132 Sycamore Street 814 North "C" Street Sfockfon, California Lodi, California Manteca, California Tracy, California ES-9-2M 10.52 Revised W-2100