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APPLICATION FOR SANITATION PERMIT Permit o. (Complete in Duplicate) .- ., _ Date Issued 3-.�---��r�, Applica4 is hereby made to�the San Joaquin Local Health District for a per it to construct and install the work herein described. This application is made in complia2.c-e with County Ordinance No. 549. JOB ADDRESS AND 6PT10iy'�1` - - Owner's Name--------- �_ ------ Phone-------------------- Address Contractor's Name-- - Phone., ` sv Q 7M1 Installation will serve: Residence ❑/Apartment House ❑ Commercial, ❑ Trailer Court-El Motel ❑ Other ❑ Number of living units:/-.____ Number of bedrooms _ 'Number of baths Lot size .___ .1 _�_�f_ ____________.__-. Water Supply: Public system Community system ❑ Private'❑ Depth to Water Table ___ _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑. Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No�---New Construction: Yesx No ❑ TYPEIOF 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_„,,')_d_...----.Material---- __ __ ------- Size__�_ Li uid de th__._ No. of com artmentsCapacity-__--- >rI -"__- Disposal Field: Distance from nearest well..Z-Y- -stance from foundation___ (_. _..Distance to nearest lot line_ /d_-L Number of lines---------- _________________Length of each line------- _ ___....�__r.Width of trench.-- �C ___.__.__________ Type of filter material _��r..k-__Depth of filter material____..__1f..______-Total length___._____._4____-____________________ t C, Seepage Pit: Distance to nearest well.. _ _._G�.�. istance from foundation_. d________-Distan e to nearest lot line f---- --� Number of pits------if____..____-Lining rriaterial__ 4"/` .<s � Diameter._.. __......De th____ Q 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------------------------------------------ 171 ---_____..____________________-_____❑ '' Distance to nearest lot lire----------------------------- Remodelingand/or repairing (describe):------"------------------------------------------------------------------------------------------------------------------------------------------------ ------------------ --------------------- ------------------------------------------------------•--------------•---------------------------------------•-•----------------•----------------....--------------- ---------'-----------------------------------------------------------••--------------------•--•-------•---------------------------------------------•---------------------------------------•----------- - •------- --• r.(S ------------------------ ---------- -------------------------------------------------•----...-----•---•--1----------------------•---••---------------•-----••--------------------------•-------•----•------ {N I-hereby certif I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat aws, d rules and regulations of the San Joaquin Local Health District. � -. (Signed)� ....... ------ -------------------------------- -------------------------------------=---------- - (Owner and/or Contractor) w By: ITitie]__.� (Plot plan, s—Fiowing size of lat, location of system in relation to wells, buildings, etc., can be placed an reverse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ----------------- ---- ----- - ----------- - -- ---------------------------------------- DATE------N�.--.---------- ----------------------------• REVIEWED BY -- -- - DATE ~-,/ --------------------------------- BUILDING PERMIT ISSUED------------------------------ DATE--------------- -------* ------------------------- Alterations and/or recommendations: - ---- --- ---- --- -------•--- ---------------------------------------------------------- --- -- - ~ -- � -- -------------------------------- ------------------------- - - - - - - ---•----- ----- --------- ----- ...------ FINAL INSPECTION BY:------: :- ------ o` -�'- - ----- - - - Date. = - -- -- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California IkES-9-2M 145446 ATWpO� 1254 k