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APPLICATION FOR SANITATION PERMIT Permit No. / ....... (Complete in Duplicate) G Date Issued ...7_"Q-_.. Application is hereby l?aae\fo�fhe San Joaquin Local Health District fora ermit to construct and install the work herein described. q p This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND L CATIO ------ - --- ---- ------- --------------------------------------------------------------------------------------------------- Owner's Name----------- - ----------,�---^------------------ ---------` ------- Phonex-_j?1/ ------------ Address-----------•-------•----------------� '-••yj..---.../�-�e�+-tom Contractor's Name....................................................--------------------------------------------------------------------------------------- Phone-"--...-----...................... Installation will serve: Residence [E- 1partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..,----- Number of bedrooms ----/. Number of baths __1... Lot size .1....O-C--IL'-,T._ Water Supply: Public system ❑ "Community system ❑ Private pt"I?epth to Water Table -T__- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[4--Hardpan ❑ Previous Application Made: Yes ❑ No 94iNew Construction: Yes [�r'No ❑ TYPE OF INSTALLATION ANIS SPECIFICATIONS: (No septic tank or.cesspool permitted if public sewer is available within 200 feet.), Septic Tank: Distance from nearest well-----------------Distance from foundation----------------.-Material------------------------------------------------- r_1 .-___-__-_-_-_- _--_-_-_--_-._--____-.-.❑ No. of compartments---------- ---------------Size.--------------------- Liquid depth----------------------------Capacity----------------------- Disposal Field: Distance from nearest well --------Distance from fou6clation _A0 Distance to'nearest lot line.____14 _________ ` ( Number of Ines______ __ __________ _ Length of each line______ --------Width of trench __ 14---------------------- Type of filte __ material. ._ .______ . Depth of filter mater �e ial jif____ _________Total length... ---___--__.-----___-___.__..._.._ V Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____---._-.-_-_.. ❑ Number of pits_--------------------Lining materia'+ -------------Size: Diameter. :____---- -- ----Dept h--------------------------------- Cesspool: _-. ---._-.-_---___. -___-__Cesspool: Distance from nearest well --- ,Art.:Distaniftom foundation- ._--------------Lining material__-_------------------------------- ❑ Size: Diameter---------------------- Depth--------- ----------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-___-..--________................_....______Distance from nearest building------------------------------------------ ElDistance to nearest lot line----------------------------------------------- ----------------------- -----------------------------------------------------•---------------- Remodelingand/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. (Signed)------ ----------------------------------- (Owner and/or Contractor) 1 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---------- - ------ DATE REVIEWED BY DATEf_ _/�-- ;; ------------------ -------------------------------- BUILDING PERMIT ISSUED--------_---------- ----•--------------------------------------- DATE--- Alterationsand/or recommendations----- --------------------------------------------"----------------------------------------------------------------------"------------•---•---- ------------ ---+ ----------- .s - ------------------------------------ 7 g k --- - ------------------------------ --------" f--------e- x--X----- --- --------- "'.._.._ x F 6l- iNS� TlO BY:. Date--------- ------- - -- - -------- -------- ---------------•- SAN JOAQUIN LOCAL-`HEALTH DISTRICT 1 r 30 S American r-eet 300 West Oak Street 132 Sycamore Street 814 North "C" Street oekkton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100