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Y APPLICATION FOR SANITATION PERMIT Permit No. .....' --!--- .. f (Complete in Duplicafe) Date Issued Applica�lion 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'----.- -----9_3__1!.�-------------------------- = Owner's Name------4:-Ih------------------------------------==•--- --- ------------------------ ----- Phone---�----��-�---/---- Address---- .. Contractor's Name------•----------- ------------------ - ------------------------------------------------------------------- Phone-3=PK_,� -------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A___ Number"of bedrooms ___:Number of baths -1------ Lot size _______S-0.x-� _______________ Water Supply: Public system K Community system ❑ Private ❑ Depth to Water Table -------- ft. 4 Character of sail to a depth of 3•feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application..Made: Yes.❑ No K New Construction: Yes X No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank:or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well_ Distance5/from foundation__._1U_ Material_-_X_�Ij 14 No. of compartments_--__�_ '7_ __ I - -- ----------- Size------ ---- X--- -----Liquid depth----�- --------------- Capacity-----� � Disposal Field: Distance from neares wellaDistance from foundation_Iq_-___--. Distance to nearest lot fine_-j------------ Number of lines___.___ _________ ___________Lengfh of each line__�4- -3�� ii� Width of french---- �a �p / Type of filter materials _1_].� __Depth of filter material---.�f.............. otal length___--"1l.,---------------------------- Seepage Pit: Distance to nearest well----_-___-_---_-_-___Distance from foundation--------------------Distance to nearest lot line_-_________-__ ❑ Number of pits.._1--------------------Lining materia!-----------------------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 nearestlot line- ---------------------------------------------------------------------- Remodeling and/or repairing`(describe):_- ----------------------------------------------------------------------••-----------------------•------------------ ----------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- ---------------------------•----------------------------------t---- ---------------------------------------------------------...---------------------•-•---------------------------------------------------------------------- t 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. i - _ (Signed) :. -------------------- --------- -- ------------------------------------------------------------------------------------------(Owner and/or Contractor) By:-------------------------- ------------4-----------------------------------------------------------==-------•---------------(Title) = (Plot plan, showing size of lot, location of s�stem in relation to wells, buildings, etc., can be placed on reverse side). ;1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ - :�`^ �AE �Z _ tREVIEWED BY --- - - BUILDING PERMIT ISSUED----- -------- --------------------------------------------------------------------------------_-- DATE--------------- ' ----•---------- Alterations and/or recommendations:'------ -----------------------------------------------•-•---------------- - -- - -- - -- - - -------------•------------ --=--------------------`------------- - ------------------------=---------------------------------------- ------------•------------------------------------------ tit ------------------ FINAL INSPECTION BY:........ 1/-...----------------------- ----- 7------- Date.'--------`z-- Z y ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT !30 South American Street 300 Wes+ Oak Street 132 Sycamore Sfreet 814 North "C" Street S+ockfon, California Lodi, California Manteca. California Tracy, California E ES-9-2M Revised W-2100