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a g APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued -__-�"zy! 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. JOB ADDRESS AND C ION __ � Owners Name------ --- -----rl --------- - - ---------------------------�f -- - ----------------------------------------- Phone----------------------------- --- Address — Cf- Contractor's Name------ 1r-------------------------------------------------- ------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ C1ammercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms ---____ Number of baths --- 1/�— of size ._ Water Supply: Public system E] Community system A Private E] Depth to Water Table , 9 4 Character of soil to a depth of 3 feet: Sand ❑ ' Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [y New Construction: Yes No ❑ FHA/VA: Yes ❑ Nov TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public seer is available within 200 feet.) Septic Tank: Distance from nearest well__.3V_Q__Distanc from foundati (,)_____.Mat ria,------------------------------------------------ _____________________ __________._ _-------- - --- - - - No. of compartments- � Size_ �1.=x__�f� „ iquid depth------ Capacity._ Disposal Field: Distance from neare t well-,564-4-Distance from foundation___- 2-'-.Distance to nearest lot lin �____-._.. Number of lines_____ ________________________ Length of each line7;,77_b_Q--!�_0Width of trenchnA Type of filter material_-$Ti'Q epth of filter material------too--_---____Total length_____/_ --------------------- �V ` Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line________________ ~' ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material---------------.----------___________ ❑ Size: Diameter--------------------------------------Depth--------:------------------------------------------Liquid _..�C.apa_citY--------------------------- u Privy: Distance from nearest well------------------------------------------------Mstance from nearest building-_-_______________________________.__-.- F ❑ Qistance to nearest lot line---------`------------------ -------------f�D rr �P Remodeling and/or repairing (describe):------------ Y -� � ! �, ._._ _ " --------- �A✓"" t'k- -------------- - - - -- - ------- ----------- _U £--------•------ .A�r- tri. � --11h'. �� .. -' - UF _______________________ _______________________________________________________•_-_-_-______-__________._____-.__-..__-___-______-_-....__-.____-_____________________.______-__-..____----________-________-____________--____----_--_--_--____-______ { I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County - ordinances, Stat an �aregulafions of the San Joaquin Local Health Distric+.Si ned ---------------- ---------- -----------------------------------------------------------------------(Owner and/or Contractor) { g ) ... By:--- -- ---------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- r (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 1 APPLICATION ACCEPTED BY------------------------------- ----- ------ ----•- ------ DATE------------------ REVIEWEDBY------------------------------------------------------------------- ----------------- DATE----------- ;j BUILDING PERMIT ISSUED-------------------------------------- ------------- - DATE Alterationsand/or recommendations-----------------------------------------------------•--------------------------------------------••-----•----------------------------------------------------- -------------------------------- ---------------------------------------------------------------------------------•------------------------------------------------------------- ------------------------------- a ------------------------------------------------------- ----------------------------------------------------------------------------------------•-------------------------------- ---------------------------------------- ---------------------•-••------------------- ---------------------- -- -----•----------------------------•-- -•-----------------------------------------•------------------------------------------------------------------- FINAL INSPECTION BY---------- -------------- --------------- Date...... .'f-- ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak Street 132 Sycamore Sfreef 814 Norfh "C" Sfreef Stockfon, California Lodi, California Manfeca, California Tracy, California ES-9-2M , Revised 1-5-Y F..P-,CO— T ^- r