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APPLICATION FOR SANITATION PERMIT Permit No. ..... �__5--� (Complete in Duplicate) Date Issued ___�� ,� Applica-ion 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. 544. JOB ADDRESS ANDCATION------ /--d-----� .-_ ------- - -' Owner's Name..... CrZ� ----- .................. Phone- Address---------------- ------- Contractor's NamePhone __` - o Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l___ Number of bedrooms �_ Number of baths _.l___ Lot size ____Sd_ � �Q U ` �� ------••-----------------------------•-- Water Supply: Public system LTJ" community system ❑ Private ❑ Depth to Water Table y t. Character of soil to a depth of 3 feet:- Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam E] Clay ❑ Adobe E-Hardpan ❑ Previous Application Made: Yes ❑ No R3---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 foundation__.---------------Material �...�/ No. of compartments----- --------------------Size---------------------------------Liquid depth--------------------------Capacity-•- - - .. � - ----------------- Disposal Field: Distance from nearest well_________________Distance from foundation____-__-_-____:____.Distance to nearest lot �"; Number or lines-----------:-- --- -------- - ------Length of each line----------- -_------------_Width of french Type of filter material-------------------------Depth of filter material-----------------------Total length---------------------------------------•-- Seepage Pit: Distance to nearest well_�TLr_�_Distance from f un ation ._ S� QD�stance to nearest lot line______________ [t}� Number of pits--- materials'/._ _ ___ _ .Size: Diamefar----____ •� ��-'-- ---Dep#h------ ��_--------•--- �, . Cesspool: Distance from nearest well________________Distance from foundation-.....--------------Lining material------------- ------------------------ F-1 Size: Diameter--------------------------------------Depth------------------------------------- ------ ------Liquid Capacity----------------------------gals. , Privy: Distance from nearest well-------------------------------------------------Distance from nearest building Distanceto nearest lot line.- --- --'---------------'--- ----'------------------ -----------••------------------------ ------- Remodeling and/or repairing (describe)-------------------------------------------------------------------------------------------------------- -------------------------------------•-•---------.._---•---------------------------------------------•------------•----------••-•---------•-•-----------------------•-------------------•---------•------------------------- •------------•--------• ---------•-------- ------------------------------------•------------------------------------ -----•-------- -----•----------------------------------•--------------------•---•--------•---------------------------------••----------------------- -------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a laws, and rules and regulations of the San Joaquin Local Health District. I (Signed)••---- -, ------- --W(00er and/or Contractor) By:._... ' - � �------------------------------------(Title)- (Plot plan, showing size of lot, location of system iv relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------ DATE---- REVIEWED BY --------- DATE - REVIEWED BUILDING PERMIT ISSUED---------------- --- - - --------------- DATE---- --------------------- Alterations and/or recommendations-------2----------- -------------------------- ---- -------------------------------- -------------------- -------------------------.--------------------------------------------------------------------------------------------------------- ---------------------------------- •------------- ------------------------------------------------------••--------- ----- 11' FINAL INSPECTION 8Y:.,-..,/ --------- Date--'---.A -.7-4`` 'r'- `,j Z SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street W4 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California E54 145446 ATWOOD