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APPLICATION FOR SANITATION PERMIT Permit No. ___?Ov. ....... (Complete in Duplicate) Date Issued Applica+ion 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. 5J9.., JOB ADDRESS AND LOCATION. `= ---------- '',fl.. .............6. ... Owner's Name--------_-----•--------- -,(r.. ------------- ---------- Ph e----••---------------------------••- 6 Address..............................................�---•-�jl�� t2l-f `�-------------•---••---- Contractor's Name............................... w ----------------------------------------------------------------- --------------------- Phone..................-- •-•--•--•--- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: J.... Number of bedrooms ._.Number of baths . ___ Lot size __ __ ............................... Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table -_____-- ft. Character of soil to a depth of 3 feet: Sand ❑Gravel ❑ SandyLoam y Loam ❑ Clay E] Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No UPJ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ser is available within 200 feet.) Septic Tank: Distance from nearest well.-5- -----Distance from fon on...�.b..`..!V". Vat�rial----� :_.. No. of compartments ____ __SlzelSrLi Liquid de th_.__ ___ Ca acit � P ,"" q p ---�-- P Y,lG�, Dis osal Field: Distance from nearest well.7-5_Z._'__Distance from foundation..�a Distance to nearest lot line__1...._)4_.. p ----------- a Number of Fines...._._,__.._..... ength of each line...... ______Width of trench____.`tL Type of filter matenalc1?- ____._._ epth of filter matenal_...�_ ---------Total length_____---76.......................... Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- IrI ❑ Number of pits----------------------Lining material- ________________Size: Diameter-----------------------Depth_------......................... —.� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining th_ material__.___-_--.-__--__---_:--_-_--_-___•. Size: Diameter----- .__------ _---.De -- -- -. -- Liquid Capacity gals. r Privy: Distance from nearest well -.-.-._ .-. ___ _. _-. _.._ Distance from nearest building. -_--_ -_-..__......................... _ ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------- ------•---------------------- Remodelingand/or repairing (describe):----- --------••---------------------------••-•-----•••--•---••••-----------•-------•-----•--•-------------••-----.._...---------------------------------V 1-11 -------------------------------------------------------------------------------------------------------------------------•------------------------•-----------------------------------------------------------•-•--•---------- fl - ------- ------------------------------------------------------------------------------ -----------••--•-----------------------•-----•---•---•---------•------------•-------. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County P ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. .. " �� C' --------------- -----------------------------------------------------------------------(Owner and/or Contractor) (Signed)---------------- -- --------- By:---•----------------------------------------------- ---- n--------------------------•----------------------- -----------(Title)--------------------------------------------------------- ------ (Plot plan, showing size of lot, location of system in lation to wells, buildings, etc., can be placed on reverse side). RT USE NLY APPLICATION ACCEPTED BY.. { ------- --- ----------- -- DATE---- / ---'� ------- REVIEWED BY..................................... v BUILDINGPERMIT ISSUED...................................................................................................... DATE----------==---• =------------- Alterationsand/or recommendations:-------------------------------------------------------------------------------.......-----------------•------------------------------.....-----_-•--- --------------------------•---------------•---- ------ ----------------------- ...................-................................................-----------------------••-•--------•---•-••-••-•-•----•••--•-----•- ---------------------------------------------------•---------------------------------------------------•...---...-•-•-----•------------- •----•......•-••--•---•------------------•---•-----•--•------------••••----------••-- ------•-------------------------------- ------------------------------------------------------------- ---------•------------------------....--------------------------------------------... ---------------------------- ---------------- -----------------------------------------------------•----------------------------------...-------------------------------- ------ ----------•----<-----------......-----...--------------------....-------- FINAL INSPECTION BY:------------ ------------------------------------ Date..----- -/•�� 7 c� H SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Steckttw, California Lodi, California Manteca, California Tracy, California ES-9-2M 14544Pf A'T 12 12-54