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APPLICATION FOR SANITATION PERMIT Permit r • �-__ e t No.�__�_ 1 (Complete in Duplicate) ' iY ' Date Issued _� AQ 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 LO ATION.______j__j__7i---------- __..... _�-fin -Owner's Name----------- ------- --------------- Phone Address----_----------_--1 i -------------------------------_-----------•..----------------- --------------------------------== --------- Contractor's Name----------------- ----------- Phone------- `----_- �, -------------------------------------------------------------- Installation will serve: Residence Ek Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I__- Number of bedrooms ________ Number of baths --------- Lot size ________-1__19-0___ ,___ `_-_ - •---__-.-_ _ Water Supply: Public systemCommunity system ❑ Private ❑ Depth to Wafer Table ,_______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No)4 New Construction: Yes]< No ❑ 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 foundafion-------.------------Material _______._ ❑ No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity------------- 1_____t' Disposal Field: Distance from nearest well------------------Distance from foundation-----_---------_----Distance to nearest lot line- EJNumber of lines-----------------------------------Length of each line------------------------------Width of trench----------:-----------------_.---_ Type of filter material-------------------------Depth of filter material---------------------_-Total length---------------------------------------- Seepage ------------ 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----1-9----------Lining material----Y___-AIU-9-----------------. ASize: Diameter------., -- ---------------Depth----------_�----------------------------------Liquid Capacity_--- -�- ------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building - ------------------- El Distance to nearest lot line___________________________________________________ Remodeling and/or repairing (describe)----------IV__✓ _ ------------ •------------------•----------•---------- ---------------------------------------------- ''•" ------- ...----------•---- 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 andregulationsof the San Joaquin Local Health District. (Signed)----------` } 7 ,---- - -------------- ---------------- - ------------------- ------------------(Owner and/or Contractpr) r =.. By:------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- --- -- ---- - ------------------------7------------------------�---------------------- DATE__-_- .,. .'_REVIEWED REVIEWED I3Y DATE --------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------- --------------- ------------------ DATE-------=--------- Alterations and/or recommendations:____________._ ------------- ------------------------ --------------------------------------------------- ------------------------ ------------------------------------- - _---- --- ! ti ------------ y ------------------------ _ -- = FINAL INSPECTION BY.-_------------------------------------------ I� --------------- Date -= ----:---------- r� SAN JOAQUIN LOCAL HEALTH-DISTRICT' _._ ' 130 South American Street 300 sf Oak Street 132 Sycamore Street u. North "C" Stree+,"� S+ockton, Californib Lodi, California Manteca, California � 1 s� Tracy; Cafifornia l s i ES-9-2M 8-51 Revised W-2100 .�IFL