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n� APPLICATION FOR SANITATION PERMIT Permit No. U (Complete in Duplicate) Date Issued 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---------------------- ------- - - ----�J-"-�D------- Owner's Name------------------------------------ ? ''! Phone Address n - = ------- ---- - --� - - �'° Phone e _ -7 l Contractor's Name------------------------------------- --- � L 0 Installation will serve: Residence [�partment House ❑/ Commercial [-] Trailer Court E3 Motel ❑ Other E3Number of living units: __/_ Number of bedrooms __!-__ Number of baths __/_ Lot size _____,� '._`, - - ------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 14"_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E❑ Adobe 2--__H�'ardpan ❑ �- Previous Application Made: Yes ❑ No �ew Construction: Yes ❑ No [A�FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) tic ank: Distance from nearest well_________________Distance from foundation-------------------Material__________.__--__--__________________---_--__. No. of compartments--------------------------Size-------------------------- ---Liquid depth--------------------------Capacity----------------------- Disposal field: Distance from nearest we �4_ "Distance from foundation__--j-Q-___.Distance to nearest lot line________---- Number of lines------------/-------_______ _ Length of each line_____3_.<)-_ _____.__.Width of trench.._-�_�____________________ S� Type of filter material___ _____ ___Depth of filter material-------��________Total length-------.,3�___----------------------- _ Seepage Pit: Distance to nearest well_ _ .___Distant r m undation___` � � ___ _______.Distance to nearest lot line____5_________ Lys Number of pits--------/----------Lining material-;� cr----Size: Diameter.____31 __._.. ---Depth------s'�5-------------------- Q, �? Cesspool: Distance from nearest well________________Distance from foundation___.__________----- Lining material_----____________________ -_-_____. 1 ❑ Size: Diameter--------------------------------------Depth........................... Liquid Capacity Y gals. Privy: Distance from nearest wel!-------------------------------------------------Distance from nearest building______________________---___--_________.__ Q ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------ -------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------_---•------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify th I have PCIared this ap lication and that the work will be done in accordance with San Joaquin County ordinances, State laws a les a reg ation of the an Joaquin Local Health District. (Signed)_ (Owner and/or Contractor) By:-------------------------------------- ---- - - -- ---------------------------------------------------------(Title) --- ------------------------------------------ (Plot plan, showing size of lot, to ion of syste in relation to wells, buildings, etc., can be p ace on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----_ (_,___M�-©_r_ --------------------------------------------------------- DATE---- �P-_r3-9_7 5~� REVIEWEDBY--------------------------------------------- --------------------•----------------------------------------------------------- DATE 1 BUILDING PERMIT ISSUED------------------------------------------- ---------------------------------------------------------- DATE I Alterations and/or recommendations:--------------------- ----------- 1�!`f""__._� _P =_g------- � K i rte- �'- - "=3 il*A7-----------------� " -----'rA-tQ----------------------------------------------------------------------------- ---------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------•-------------- FINAL INSPECTIQ BY:. - -- ---- --- ------- ---- Date-------- -- f 7775 ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street 1\\m� Stockfon, California Lodi, California Manteca, California Tracy, California 4 a ES-9-2M Revises 1.57 RP.CO.