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APPLICATION FOR SANITATION PERMIT Permit No. 4110 - (Complete in Duplicate) Date lssueda�l 6-- /, 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. J06 ADDRESS AND LOCATION.__. Owner's Name _ e�- ------------------------- _____________ Address -- ---- -'-'--- Phone ------•-•-----••-------• ---- -------------------- --__-_-- -----------; 0- -,Contractor's Name/Y-.-----------------•----_-- -- ---•- -------- ----- ----- --------•--------------------- ------ ------•-•---_ • -- Phone----------------------------------• Installation will serve: Residence Apartment House ❑ Commercial X Trailer Court ❑ Motel Number of living units: -------- Number of bedrooms -------- f—❑ Other ❑ r _. -Number of baths _ ____._ Lot size ______ __- -" Wafer Supply: Publics stem Y ❑ Communitysystem � ._ - - ---------------- �- ---- o Water Character of soil to a depth of 3 feet: Sand [� Y Grave❑I ❑PrlSandy�Loape(j tCiay Loam E] Clay ft pth Previous Application Made: Yes ❑ NoConstruction:❑ Y ❑ Adobe ❑ Hardpan, ❑ [K New Yes 0 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r .. (N9_saptic. fank.or;cesspool_ permitted. if -public sewer -is -available within 200 -feet.) - - Septic Tank: Distance from nearest well__, ep Distance fro foundation_-_ __ ___ No. of compartments �/ �� p Size-/' -_ Liquid depfh----- Capacity 4� Disposal Field; Distance from nearest well -/f pistance from foundation -- --,----.__Distance to nearest lot line19 _ ^�Q--�-_-- Number of lines -------- --___- Length of each line____.____,'�__G Type of filter material--� _ -- Width : of trench_wkv� cDepth of filter material__ ---f----__ Total length__ -__- -------------------- Seepage Pit: Distance to nearest well- -_------_ - Distance from foundation___________________,Distance to nearest lot ❑ Number of pits ---- E__ --___---_----Lining material -----------------------Size: Diameter---------------- ------- Depth ------------------------------ Cesspool: Distance from nearest weil-------------- --_ Disfance from foundation __---_----__--- ❑ Size: Diameter------ 16------------- lining material----_------------- ---------Depth--------------------------------- ................Liquid Capacity ----------- gals Privy: Distance from nearest well-------- --------- g . ------._--_._-._Distance from 5nearesf buildin ❑ Distance to nearest loft line------- --------------- ---- g- ---- ----- -- -------------------- - ------------------------------------ ---- Remodelin and or repairing (describe): --- 0 - ---------------------------------------•-----------•------------------•---•----•-----------•---•--------------------------------------------------------------------------------- - I hereby certify fhaf I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law and rules 4pd re Qlafions of the San Joaquin Local Health District. (Signed) -------------------- ------ ----------------------------------------------------------------------------------- -- -- er �'*.--------------- - ------------------------ "- _< = '-------_-------------- --- -- ------ ---- ---(Title) '_` =-Owner-/or�Contractor] —.� (Plot plan, showing size of'lot; location of system in relation to wells, buildings, etc., can be placed on reverse side). F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ -- -- - J t REVIEWED BY--------------------------------------------------------------------------------------------------------------- DATE------------- ----- BUILDING PERMIT ISSUED--- ---------- DATE----------------------- - - DATE Alterations and/or recommendstions:___----------------- - -------- •------•------------- -- -------------------- - ------------------------------------ FINAL INSPECTION BY:_..-_ -- --- ----------------------- - -- Date---------- . -- --- -- �------ ---•-- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+ree+ 300 West Oak S+reet 132 Sycamore Street5+ockton, California 1' 914 North "C" S+reet Lodi, California Manteca, California Tracy, California ES -9-2M �0-52 Revised W-2100