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alpp APPLICATION FOR SANITATION PERMIT Permit No. I?: d�: (Complete in Duplicate) Date Issued/n'.._k2.:•��-� 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. r JOB ADDRESS AND LOCA IPhone--------------------•----------- ON---• --- -- -- -------- ---1 -- t"----'-•--------------------------------- ----------------------•------- Owner's Name- ------------- --------- -- Address------------•----------------- IPhone----•---------------•---•--•-----• Contractor's Name----=---••--------------- '-------•-----•-------•-- ----------------------•-------------------------------- Installation will serve: Residence ❑ artment House ❑ Commercial Trailer Court ❑ Motel ElO�th`er�❑ �'pE] Mumber of living units: _A___ Number of bedrooms ___r___ Number of baths ._1___ Lot size Water Supply: Public system ❑ Community system ❑ Private E4--Depth to Water Table ________ ft, Character of soil to a depth of 3 feet: S'pd El Gravel F1 Sandy Loam ❑ Clay Loam ❑ Clay El Adobe E3--Hardpan ❑ �1 Previous Application Made: Yes I No ❑ New Construction: Yes �I�o ❑ " TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t �n n--- Septic Tank: Distance from nearest well-.674. _ __'Distant fro ounda ' n__.f __ Material- -- Flo. of compartments!------�______..__Size___ e/�--- �- --Liquid pth__.___ _ -- -- ------ Capacity = Disposal Field: Distance from nearest' well____ istance from foundation_-_14--rLance to nearest to line_!. _ ___-- Length of each line 's-' ________________-:Width of trench.____ .�"'f-.- -- �r/y[� Number ai lin --------------' "-- g 7 r , /e i T e of filter material._-_ _<_ �-_Depth of filter material__).( --------------Total length--- __!�__rine ----------- Yp A 3r ' i Seepage Pit: Distance to nearest Well------__--------------Distance from foundation....................Distance to nearest lot _.______--- Number of pits---------------------Lining material-----------------------Size: Diameter_--------------------Depth---------- ------- - + Cesspool: Distance from nearest well _____________---Distance from foundation--------------------Lining material-----------------.--____.____.___.__ Size: Diameter Depth _ Liquid Capacity gals. 4 _ ❑ « -_ v Privy: Distance from nearest well--------------------------------------------- -- Distance from nearest building-----------------------------------------. # �i .. ❑ Distance to nearest lot line --- ---------- ------------------ "t 3 Remodeling and/or repairing (describe):--------- --------- -------------------•--------------------- ---------•----•----------•-------- 1. -•-----•-•------------------------------------- ----••--------------------------------- - -------------------- ---------- --I----•-------•---------------------•----------•------------•---------------------•------ __ __ I 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. „ - -----_--.______Owner and/or Contractor) (Signed)___�. _ ��'� _ 't -. - -*',-- _. .__. � ( i 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 rrjj APPLICATION ACCEPTED BY------------ - ------ ------------------------------------ DATE- ---�----- ----- ---- --------- ' DATE---------------------------------------- ----------- REVIEWEDBY-------------------- --------------------- ------------- -------------- ----------------------- ----------------------- ---- BUILDING PERMIT ISSUED_----------='------------- ---------------- ------------------------------ DATE_. Alterations and/or recommendations------------------- ---------------------------- ---------------------------------------------------------------_---------------------------------•--------- -------------------- ----------------------- ,. _ _. ------------ ----------------------------------------------- ---------------------------•---------------� -----------------•- ------- �. -------------------- --------------------------------------------- f _ � / �. FINAL INSPECTION BY:------L'--<'�--J--------------------------------- Date_.... ! �f---f ------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT i 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak 5trae+ Y Stockfon, California Lodi, California Manteca, California Tracy, California £S-9-2M io-52, Ravised W-2100 "�a.