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a A `a APPLICATION FOR SANITATION PERMIT Permit No. _ -------------- (Complete __ '-_(Complete in Duplicate( /p Date Issued AV3= 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 LOCATION---------------- i? Owner's Name-----------------------------4- /./__0-------------- r �'---------------------- -------- Phone �. Address------------------------------------- - 1,f ----------------------------------------------------------------------------------------------------------------------------- Contractor's Name----------------------------------------- ' _ R'-------------------------------------- --------- Phone -------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms____ Number of baths ---k Lot size ________________•+� 7__ x,,0 Water Supply: Public system E] Community system '❑ PrivateK Depth to Water Table __& ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�� Hardpan ❑ Previous Application Made, Yes E] No New Construction: Yes No ❑ x TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from neare # eel�S_ r __ Distance from foundation----/d----------Material___ No. of compartments s_. ---- Size----� ---Liudepth- ------ _-----Capacity acit --------___�___ _� , E Distance from foundation---osa Field: Distance from nearest well_ ____ .D � _-___Distance to nearest lot line_ Number _ 4E of lines-----__ ,,__�_�i +, Length of each line____________ ________-.Width of trench-______-_�'_�___-___ Type of filter material___�� ,..Depth of filter _____Total length__________________l�-__--------- Seepage Pit: Distance to nearest well._--------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-------_-------------_----------- r Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material_______________ ❑ Size. Diameter-------------------------- -- --------Depth----------------------------------------------------Liquid Capacity-,--------------------------gals. Privy: Distance from nearest well____________________________ ___-_______-_Distance from nearest building------------------------------------------ F1 Distance to nearest lot line Remodeling and/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)- ------ ------------------� f ' --•- ------------------------- --------------------- ----- ------------------------ ----------•------- - --(Owner and/or Contractor 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--------- 2'-- - r - ,= ;------------- REVIEWED BY .... -------- . - ----k_!i�- - ---------------------- -------------------------------- DATE "'"A BUILDING PERMIT ISSUED____ /�- ----------------------- -------------- ,Alterations and or rec mendations:___jn_ - --------- --• --------- --------------- --- _ __j------- ------------- ----------- ".4------------------- -- ----- -------------- ---------------------------------------- CA_ t FINAL INSPECTION BY:_ 4_= ' ----------------- Date � •` ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California ES---9-2M 8-51 Revised W-2100