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1' APPLICATION FOR SANITATION PERMIT Permit No. .___ (Complete in Duplicate) 4 Date Issued _____I?/7_-/s L Application is hereby made to the San Joaquin Local ealfh District for a permit to construct and install the work herein described. This application is made in compliance with Cou ty 0 ina ce No. 549 JOB ADDRESS D L CATI - 11 ------------•--------------------------------------••--------------------------------------- Owner's Name------'=� � ' -----j�--- --- - -----.-------------------- ------ --- ------ Phone--- _- -- - ---------------- -- - ----------------------------- - Address_-___ V - ---- ----------------- ontractor's Name_. ,�_"""_ _ " "" _ "" - ------------------------------------------------------------------------ - Phone---•-------------------------------- Number ---------------- ---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ 1 Number of living units: __.�___ umber of bedrooms __�___ Number of baths __ ---- Lot size ---/' -/ - ---------- -- Water Supply: Public system Communifi system Y y I] Private ❑ Depth to Water Table ______ ft. Character of soil to a depth of 3 fee+: Sand Gravel ❑ Sandy Lo; No ClayLoam Clay❑ y ❑ Adobe �ardpan� Previous Application Made: Yes ❑, No New Construction: Yes ❑' l TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundaTion____-___________._-.Material _______________.___-_____ ❑ No. of compartments--�- -------- ---------Size-------•---------------------Liquid depth------------------- ------Capacity------------------- Disposal Field: Distance from nearest well_______________ Distance from foundation--------------------Distance to nearest loft line________________. ❑ Number of lines---------------------------------Length of each line------------------------------Width of trench Type of filter material-------------------"" --Depth of filter material----------------------- length------------------- -_-_-_--_-_ 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 CapacitY----------------------------gals. Privy: Distance from nearest❑ well ______________________ Distance from nearest building --------------- Distance to nearest to me__ __ ___ ------------------------------------------------------- ----------------------------- R oaleling an epa)rmg (clescribe):_ - ---- - ------------- -- - - - -------- ---- - - rt --------------------------•- 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)------- , -------- --------I------(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_„ '--------------------------------------------------• s REVIEWED E - ----------------------- DATE- Alterations ------------------------------------------------- BUILDING PERMIT ISSUED---------------•----------•----- DATE - - -------- ------- ------------------ -- ------------------------------------------------------------------- DATE---------- ------------------------------------------------ ':Altera+ions and/or recommendations____________________ ------------------------------------------------------•-------- -------------------------- ----------- ---------------------------------------- ---------------------------------- - -- ------------ ----- --`-'v/1, --------- ------- -------------------------------- -------------------------------------------------------------- ------------------------------------------------------ `�� ----- ------------- - - f •: 3- Z Z sG f FINAL INSPECTION BY 3�---"_-"-- -- . --- ----------- - �------- - ate--------- �-------- ___ _ 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