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1 APPLICATION FOR SANITATION PERMIT Permit No. ..... 'T. ' �Com lete in Duplicate) p 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.__��r-Q.�__ .� ___ _ _ __ � ________�+ -�I- Owner's Name----------------- ----•-------•--------...A_Nd_R tF__m/------- 45.e4 ---------------------- Phone-----C Address.............................. ------------------------------------- -`--------------------------------------------------------------------- Contractor's Name -.--X_P_YZ�4---•----r-w-`--'---------------------- ••--- --------- ------ Phone------- Installation will serve: Residence)< Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. _J____ Number of bedrooms A3---- Number of baths _ Lot size ____LQ_ -_-_-_____..__ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table _j/' a ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2K Hardpan ❑ Previous Application Made: Yes ❑ No Q( New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearest well-________________Distance from foundation--------------------Material__*---------------.------------------------------ 1—:®iq9 No. of compartments--------------------------Size------------------------•-------Liquid depth---------------------- . Capacity-----------------------�+" Dis osal Fi Id: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line__------___._____ Number of lines----------------- ------ ------Length of each line----------------------------Width of trench-------------------------- ----•- Q Type of filter material-------------------------Depth of filter•material____.___._ ----Total length------------------------------------------ See e Pit: Distance to nearest well-r-�-.OS`-\F---__Distance'from foundation_____ ______-._.Distance to nearest lot line------- Number of pits_____l_______________Lining material-e- Size: Diameter____- �.�__.Depth____AZZ c_______ Cesspool: Distance from nearest well-----------------Distance from foundation _._------Lining ❑ - material_ -._-_--_.._.--________.___________-_ � ---Size: Diameter----- ----=---------------De th-------------- - ` -- Li uid-CaPacity-- ---------------- - gals, -�- Privy: Distance from nearest well------------------------------------------------- g------------------------------ _____________Distance from nearest building _-__-.___--. ❑ Distance to nearest lot line-------------- ------------------------------- ---------------------------+"-------------------------------------------------------- ------ Remodeling and/or repairing (describe)------------------------------------------------------------------------------------?-•------------ -----------------•-•--------------------------..__...__. ------------------------------•----•------------•---- -------------------------•-•--------------------•-------------------------_...-------------------•-•----------------------------------------------------------------- -------------I----------- -------- - --- ----------•--------------------------------------------- ---------------------------------------------------------------------------------------------------------------. I hereby certify + t l ave prepared his application and that the work will be done in accordance with San Joaquin County ordinances, State law and ules a d reg ations of the Sa Joaquin Local Health District. (Signed)----------------------- -- ------- -- --------- - - ---- -------------------------- (( Contractor] By:--------------------------------------------------..---------------------------- --- ; ----- (Ti+le} �.? T ------- (Plot plan, showing size of lot;location of system in relati to wells, buildings, et can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = ------------------- ------- -------- 1'--------------- DATE---- D I�s----'�------------------------ REVIEWEDBY------------------------r------ ----------------------------- ------------------------------ ---- ----------------------- DATE---•------------------•--------------•---------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------ ------------------ Alterations and/or recommend ations--------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ------------•--------------------------------•------- ----------- ----------------------------------------------------------------------•----=-------------- ------------------- ------ -------------------------- ----- -------- ------------ ------- 1 FINAL INSPECTION BY:..... - ---------------------------- Date....�--------�-------- ---------------------------r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Sfockton, California Lodi, California Manteca, California Tracy, California ES-9-2M �0-52 Revised W-2100