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1 APPLICATION FOR SANITATION PERMIT Permit No. _- / (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 o. 549. } JOB ADDRESS OCATIO -----------0___ _ _ Owner's Name ------ -AIV - s' _------------------ Phone--------' ------. - ---------- ---------------------- Address------------CQ..49-- q--- ---- -- ------• Contractor's Name---- •--- •--- ----------------------------------------------------------- -------------------------- ...------------ Phone------------------•-•---------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motef ❑ Other/ ❑ !' Number of living units: _ -__ "umber of bedrooms -7-_ Number of baths .__!.__ Lot size �.�-__� 1Q�0 ------ ----- -------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: _'SandEj Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan E]Previous Application Made: Yes [I No 'of New Construction: Yes do ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public se er is available within 200 feet] ' Septic Tank: Distance from nearest well__ / /n� '"+/' ( istaryc`e fro 4oun tion.1!/_�ate laf_ _ _ - - ------- - ----------- [� No. of compartments-------- -- -------- Sizes0.-�_Y-_�1___-_;_Liquid depth------- r Q� Capacity U Dispos Field: Distance from nearest wel-.. ._Distance from foundation/+lis#ante to nearest lot 'n . Number of lines----_----- • -_----- -_ --_ f '- Length of each line------��-- -- Width of trench...------.-�- l/---- ----- Type of filter materi ��-Depth of filter materia---------- ---------Total length----------- _Z_L!_-----------•-•-- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line.__---....._._. ❑ Number of pits----------------------Lining material-----------------------Size: Diamefer__---------------------Depth--------------------------------- Cesspool: Distance from nearest well----.----_..._--Distance from foundation....................Lining material--------------------------------------- ❑ Size: Diameter----- --------------------------------Depth------ ---------------------- ---------------------Liquid Capacity----------------------------gals. r Privy: Distance from nearest well----------_-------------------------__----------Distance from nearest building ❑ Distance to nearest lot line--------------------------------------------------_ Remodeling and/or repairing (describe);-------_-------------------------------------- -------------------- --- ------------------------------------•-----------•-------•-------------------------------------------------------------------------------------------•----------------------------------------------` r ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to 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--X-"-, REVIEWED BY . -------------- DATE S - -- ------------------------------ - UILDlNGPERMIT ISSUED ------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations___ ,__--_• _ -------__-_----- ---- u - ------------------------------------- ---------------------- ------------ ----------------------------------------- ---- ------------------- _-------- - -- - - - 1cti�Z1j� ([z ----------- --------------- -- �/ u'" FINAL 1, `�E�'SIT©l�h�$ ------ ---------- Y ------- Date-- --------------------- - ------------------------------------ ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 30��i.�aauttt hwr;can Street + 300 West Oak Street f 32 Sycamore Street 814 North "C" Street Sfoc-64, CalJorma Lodi, California Manteca, California Tracy, California t. " s' ES--{9-2M ID-52 Revised W-2100