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��4� IV APPLICATION FOR SANITATION PERMIT Permit No. {Complete in Duplicate) Date Issued, I Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. t This application is made in compliance with County Ordinance No. 549. ` JOB ADDRESS A LOCATIO1N---- / �' --Q-----------�-�/✓ -C�7°'----------------------------------------------------•----•---------------------- �►' . _TT l� S---------------------•----------------------- ------------------- Phone--------••-•--------------------•--- Owner's Name_ _f__�______ ___. _ ------------------------------------ Address--------------- a---------- •-•--------------------------••----------------------------- ------------------------------------------------------------------ Contractor's Name----- a,- ----- ---------------------- ---------------------------------- •-------- Phone----------------------------------- Installation will serve: Residence Apartment House [I Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j----- Number of bedrooms _A. Number of baths _,/_ Lot size ----T�-d------X--.-?O------------------------- Water Supply: Public system _Community system ❑ Private ❑ Depth to Water Table 4_0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Q}—New Construction: Yes R No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Septic Tank: Distance from nearest well-----------------Distance from foundation----------------.-_Material.--_----_._.___-_------_._---.___.--.__...____-. ❑ . of compartments-- ----------------------Size---------------------------- ---Liquid depth--------------------------Capacity-------------------•-- Disposal Field: Distance from nearest well..............._Distance from foundation-------------------.Distance to nearest lot line__-_____--------_ f ❑ umber of lines-----------------------------------Length of each line------------------------- ---.Width of trench----------------------------------- + YPe of filter material.........................Depth of filter material---------..----_---.----Total length------------------------------------------ Seepage Pit: Distance to nearest weIL-IV4 r—4.__Distance�m foundation____� -_-----Distance o nearest lot line__________-. M_ Number of pits-----f_______________Lining material-___.G G� _-Size: Diameter..... -_..---Dept h____u�_,7_' Cesspool: Distance from nearest well-----------------Distance from foundation---------------.-_. Lining material-----------------...____________-_-__. ❑ Size: Diameter--------------------------------------Death--------------------- ------------------- ------Liquid Capacity-.--------------------------gals, . Privy: Distance from nearest well------------------------------ ------------------Distance from nearest building----------------------.------------------. ❑ Distance to nearest lot line-------- ----------------- --------------------------------------------------------------------------------------------- ----------- " Remodelingand/or repairing (describe):------------------ --------------------------------------•-----•------------------------- ---------------,-•---- -••-----------------------------•---•-- ------•------ ---------------•-•--------------------------------•----•------------------ ----•---------------•---•-•----------------------••--------------•--------------------•-----------------•--•------------------------ -------------------------------------- --------------------------------- --------------•-----------------------------------------------------------------------.----------------------------... ----------------------------- ---------------------•------- -------------------------•-----•------------- -----------------------------------------------------------------------------•--- ------------- I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, Statei , and rules and regulations of the San Joaquin Local Health District. (Signed) ---------------------------------------------------------------------------r--------(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 APPLICATIONACCEPTED BY ---- - ------------------------------------------------------ DATE----= -----•----------------•------------------------ REVIEWEDBY - DATE----------------- --------------------------------- ------ BUILDING PERMIT ISSUED. '"=�-------- DATE n Alterations and/or recommendations------------------- +,: = ------------ -------- ---------•- # - ------------• ------------------- ? ---------•------- +I f L� -� -r\ -------------- -------------------------------------------------------------- ------------------ - -----------------------•-------------------------- - ---------------------- Date_. � r �� FINAL, INSPECTION BY:. --------�teA --- SAN JOAQUIN LOCAL HEALTH DISTRICT ''110 South American Street 300 Wes} Oak Street 132 Sycamore Street 814 North "C" Street � '",ocktop, California Lodi, California Manteca, California Tracy, California 145446 PTW❑D 12.54 1