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r I� - i APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) M Date Issue 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. 549, 604 JOB ADDRESS AND LOCATION- ___ _ ____ - a a -4 Owner's Name-----�-------`.. �_ , � - --- --- ---- � - Phone Address--------•---_.-__... - --------------------- -- ------------------------------ iN /= -------- -- � -- -------- Contractor's Name-----•-------••--------- # � -----•-----•- --------------------------------------------------------------------------------------------•----- --------------- Installation will serve: Residence r hone_._"_____________•-_ Apartment House ❑ Commercial �t ❑ Trai ler Court ❑ � Motel [] . Other Number of living units: -------- Number of bedrooms _______ Number of the / ----- - Lot size ------------ I system ❑ Community system - Water Supply: Public Y Y [Q Private Depth to Water Table 0 ft. Character of soil to a depth of 3 feet: Sand ❑ -ravel ❑ Sandy Loam Clay Loam ❑ + Previous Application Made: Yes Clay [3 Adobe Hardpan E]No ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: '(No septic tank'or cesspool permitted if public sewer is available within 200 feet.) s Septic Tank: Distance from nearest w�lr �-----Distan e fr m fo�+n ation No. of compartmerifs �[ � ------Material ----- -- ---------- Size !` ---K3------- depth__ ----------Capacify--1-_Yd U---- Disposal Field: . -Distance from nearest well !1'1x- 75pi5tance from foundation-/_-*-,-- Number of lines____._---------------- --=-'Distance to nearest lot line_��^�-,-, Length of each line-------- -_ --------..Width of trench. 2_�•`--------------- Type of filter material--` cr .-----Depth of filter material yy r -_._Total length___4__,�_________ Seepage Pit: ' """ '"'Distance `to nearest well-----------------------Distance from foundation____-________-. _Distance to nearest lot line_________________ ❑ Number of pits--------------------- Lining material________._ _ Diameter---..-' I r -----------Size: ----------- ------Depth-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-----------------1_Lining material--------- ___________._ -------------- Size: Diameter--------- ---------- ------------- -Depth----� �------ -----•=-- --------- ---- --- - ---Liquid Capacity --------------------------gals. Privy:' Distance from nearest wellDistance from nearest building ❑ - Dir ante to-nearest lot line 9 --------------------- -------- I --------------------------------------------- Remodeling and/or repairing (describe)--------------- ------- r ----•---------------------- t ---------------------- 1 ---------- ------------------------------ ----------------------------------------------------------------------------------------------------------------•----•-------------•------------------ 1-hereby certify-that I have prepared this application,and'that the work will be done in accordance with San Joaquin County ordinanc laws, and rules and " u afm"; of th, a oa 91tin Local Health District. 1 (Signed)__ ._ --- --------------------------------------- ------(Owner and/or Contractor] -- --------- Y By: h n f lot, to-------------- (Plot ------ ----------------------------------- -- - ----------(riifle)---------------------- -------------------------------------- (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----------------------------- -- f -- - ---------- --------- -- -------- -- __._ DAT -----------•-------...-----J �------- -------- - BUILDING PERMIT ISSUED ---- DATE. ----------------------------------- Alterations and/or recommendations-------------------------- -------------------------------------------- ----------- -•-------------------- ---------------------------------------------------- -------------------------------------------------------- ----------------------------- ---•---------•--------------------• ---- -- --------------------------------- - ------------ ----- ------------------------------- ---- ------------ - --- FINAL-INSPECTION-BY:_.__._.._____- Date__._._. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132SycamoreStreet 814 North "C" $}rae+ S+ock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100