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(W �„ APPLICATION FOR SANITATION PERMIT :. Per it No.v-.-- __ ._. (Complete in Duplicate) Date Issued .--.--- Applica+ion is hereby made to the Sa ' Joaquin Lo al Health District for a.permit to construct and insta it the work herein described. This application is made n complia4nce with County'Ordinance No. 549. JOB ADDRESS AND LOCATION---------------------- ------• "------€ ------------------------------------------------------ ------ -- • - Owner's Name------------ J-1-0------ .iC__ ��` ---,-- ----- ---- --------Phone------------------------------------ Address----•---•--••------•-------•-------------------- Contractor's Name------------------------------- -'- ------ Phone------------------------- -------- i Installation will serve: Residence x Apartment House ommercial El Trailer Court El Motel 0 Other E31 !Number of living units: ________ Number of bedroo s __Z__' umber of baths -------- Lot size ---------�___,t ___ ____________________ Water Supply: Public system4 IL Community system ivate ❑ 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 ❑ No New Constructigr�:_Yes No E] F TYPE OF INSTALLATION AND SPECIFICATIONS: r � I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) l _ .r f Septic Tank: Distance from nearest well_____ __��_ Distance from foundation___10__________ n '__-------- Material ___ _ 1."1- No. of compartments-----------I—----------Size.---.:: -X ----Liquid depth-------1-2--y- ------Capacity-----f`sa_- fj4i�l Disposal Field: Distance from nearest well----/ ------Distance from foundation------- D_--___.Distance to nearest lot line_____ ...... Number of lines---------------=L._ ...----------Length f each line------ ....Width of french----------- Fy------------ ' Type of filter ma _______Depth of filter material------- -5r/!____._Total length___.-------4W ___________________ Seepage Pit: Distance to nearest well----------------------Distance; from foundation--------------------Distance to nearest lot line--------______.__ ❑ Nu e bar of pits----------------------Lining material--------------------- Size: Diameter-----------------------Depth---------------------__---------- Cesspool: Distance from nearest well_-______-._____Distance from foundation---------------------Lining material_____________________________________ ❑, Size: Diameter-------------------------- -- I------Depth=_ _ Liquid Capacity gals. Privy:i Distance from nearest well---------- __�*,___Distance from nearest building-----------_---_---_________________..._. ❑' " Distance to nearest lot line--- ----------------1#._e-- 2 -- --I----------------------------------------- ------------------------------------- Remodeling and/or repairing (describe):--------- -----------'-------------------------............•----------------------------------- --..... ----- ,.f 4 1:,.___.�__4 ----------------------------------------- ---------------------------------------------i----------------- --t----------------------------------------------------------------- ------------------------- } ------------------------------------------------------------------------------------------- -------------........-------------------------------------------- ---------------------- - - --_--- - _-- �-�-�-------------------- -------------------------- 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 iHealth District. (Signed) x -------• ------------------------------=--------------(Owner and/or Contractor) ....z :.b (Title)--------- -------- (Plot plan' showing size-of lot, location of system in relation to wells, buildin4s, etc., can be placed on reverse side). p l FOR DEPARTMENT USE ONLY F APPLICATION ACCEPTED BY-------------------------------------- - -- DATE------------- r�- --- - _ REVIEWED BY----------------------------------------- - DATE - --- ---------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------- -- ••----------- DATE------------- ---------------------------------------------- Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------.------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------•-------•------------------------------------------.---------------- ------------------------------------------------------••---------------------- ------ ------------------------------------------------ ------------------- ----------------------------------------------------------------- i - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------- - --------- -------------••---------------------------------------- ----------------------------------------- -------------------- FINAL INSPECTION ' BY-------------------- Date...------ -------------------------------------------------------- SAN J ---: . SAN JO■AQUIN LOCAL HEALTH,;DISTRICT 130 South American Street 300 West Dek Streef 132ASycamore $tree+ 814 North "C" Street E/ Stoc6on, California Lodi, California Manteca, California Tracy, California ,6-9-2M Revised W-2100 !