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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) S Date Issued ___ A�__._�� 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. 5,499.. JOB ADDRESS AND LOCAYION_ _ .__ ` == =` -------------- Owner's Name 1 �.� - d� 14 i �� rT.{► ' Phone Address---- M-1- ----------------------------=-------------------•---------------------------- -----------------------••------------------------------------ Contractor's Name----- --------------------------I------------------------ ---------------•--------------------------------- Phone------------------------•---------- • Installation will serve: Residence [1/Apartment House ❑pp Commercial ❑' Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _.__ umber of bedrooms ---- „Number of baths ______ Lot size ___ ?�... -- �-1 ----------=-------------- . Water Supply: Public system Community system ❑ Privete'❑ i'Depth to-Water Table -------- ft.' Character of..soil to a depth of 3 feet:{ Sand [] Gravel ❑ Sandy Loam ❑. Clay Loam ❑ Clay ❑ Adobe a pan ❑ Previous Application Made: Yes ❑ No / New Construction: Yes VNo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND.SPECIFICATIONS: -,- ( septic p p �pIw.sewer is available within 200 feet) 5e #ic 5- tic tanDk tancesfroml nea e'st well_/_ 11 istancr e from #ound ion_ff_//-�� if.'public No.. of compartments------- : __-____----Size-- -- - -- -- ----Liquid deRth--------- --------Capacity.-- � -- Disposa Field: Distance from nearest llp_4WDistance from founclationl _Distance to nearest lot line...I - W idth of trench--- ---�t--`-��'---------------- - Number of lines--------------- -��--------------Length of each line------------�------fj---� f Type of filter material t 1— Depth of filter materia4____.__1�___.___.Total length__________ -________________________ Seepage Pit: Distance to nearest well__________-_ __'Distance from foundation____________________Distance to nearest'lot line._____:___...__._ "V ❑ Number of pits--------------------I Lining material-----------------------Size: Dia meter------------------------Depth-----.-.------------------------- Cesspool: ------------- ------Cesspool: Distance from nearest wed-----------------Distance from foundation--,_____________.Lining material_____________________________________ \El � Size: Diameter-------------- - - Depth-------------------------- ------Liquid Capacity---------------- -------gals. �U Privy: Distance from nearest weh____.__'_'-----------------------------------------Distance from nearest building------------------------------------------ ------------- ❑ ----------- - -------------- - Distance to nearest lot�line - ---------------n- ------------------------------------------=----- t _____________________________________________________-.-.-___ R�mode"it and/or repairing [describe}::___-- ___-- �., ---------------------------------------------------------- -- ------------------------------ ----------------------------------------------------------------- -- ---------•--•--------------- -------------•-•-=------'-�-- I _ - i --------------------------------•---------•--=-----------------------••-------_-•--------•--- ----------------------------- ------------ ----- -------------------------------------.----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. �r Oi (Signed] - - t a. Contract {Owner and/or or] , x ------------------------- By:-------------------- {Title}-----------------------------------------------.------------.- - (Plot plan, showing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY) — -------------------- --------------------------------------------- --------------------- DATE!!— —1-1`-------- IC K REVIEWED BY-- --------------------- ----- °-------------------------------------- DATE__1F ---------•--- ------------------------------------ BUILDINGPERMIT ISSUED-------- - =---------------------------------------------------='--------------------------- DATE---- --------------------------•------------------- Alterations and/or recommendations:---------------------------- ----------------------- ---------•----------•----------------------------•---------•- •-------------•------------------- ....-------••---------- f• -------- -------=----•-------------- ------------------------------•-------- ------------------------- I E . ---------------------------------------- -------------------------- --•---------------- -------------------------------------------------- AFINAL INSPECTION BY:- v.. ---------•--------•--------- -• •--------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Stree+ Siockion, California Lodi, California . Manteca, California Tracy, California ES-9-2M , Revised 1.57 F.P.CO. !