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r APPLICATION FOR SANITATION PERMIT Permit No. _____ 3_ _3 / ' (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 No. 549. JOB ADDRESS AND LOCA 1 ----•------ ;�-- -----�- ----------- --- wner's Name_____________ _ --------- -_- I - - ------ --- -------- -- - ----- - ---- - ----- ----------- Address l one - ------ ----------- ------------ --- ' _ Contractor's Name----- ---------- --�-�-- --- ------ ---- ---- -- -- - -- Phone-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___r_ Number of bedrooms_- Numb�� he __ I � Lot size ---- Water Supply: Public system ❑ Community system ❑ Private to Water Tabl ft. i Character of soil to a depth of 3 feet: Sand ravel Sandy Lo;�Nlo Loam Cla Previous Application Made: Yes [] No New Construction: Yes E03y ❑ Y Adobe ardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: e " istance from nearest well_________________Distance from foundation-------------------- ❑ "® Material--------------------- ------------------- -----• No. of compartments------------- -----------Size--------------------------------Liquid de th Capacity ------------------- Disposal Fi Distance from nearest weil_�--� .Distance from foundation_ Y_(/- Distance to nearest lot li „--- Number of lines___._ Length of each line_____ � �-`-- _.Width of trench------..._,7-- ----------- Type of filter material4 _en-r/Depth of filter material____ __ -- ,� --�---�---Total length---------�'v-�-------- O . eepage Pit: Distance to nearest well----------------------Distance from foundation_._________._.._.__.Distance fio nearest lot line__-___________.-_ ❑ Number of pits______________________Lining material-----------------------Size: Diameter----------------------- Size: - Depth--------------------------------- Cesspool: - Distance from nearest well-----------------Distance from foundation__-_____ __.Lining material___________________.-_ ❑ Size: Diameter--------------------------------------Depth------------ -----••-------- ----------------------------------------,r: t :. 1::�:� c. .�:, =- aqui apacity- gals. Privy: Distance from nearest well""`-`"-. --4'.�-.. -�, .-_-�•—- �: ----------------------------------- ----- ----__------------ Distance from nearesfi buildin Distance to nearest lot line_______ __________ g-- -------------------• ----------•------ ----- ------ ___ Remodeling and/or repairing (describe):_ _ _ _ ------- ► .01------- ---------------------------------...... ------- ' =---------••---------••-------------------•- -----------------------------------------•--------------------------------------•-----------------------------------------------------------------------------------------------------------•-----•---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rul s and 'r laf•ons of the San J aquin Local Heal D' tricf. (Signed)----------- s (Owne nd/or ntracfor) By:------ --------`•• A_----- - -- -- ------- - - -------- ---- - ------ ------- ----(Title)- (Plot plan, showing size of lot, locafion'of sysfem in relation to wells, buildings, etc., can be placed on reverse side). ------------------ FOR DEPARTMENT U--------------------- SE ONLY APPLICATION ACCEPTED BY------------ - ---- DATE---------- R1 VIEWED BY- ------------------------------- -- ----------- ---- r -------------------------------------------- DATE BUILDING PERMIT ISSUED- ------=--- ----------- ---------- - --------------------------------------- Alterations ------------------------------ --- -------------------------------- ----- DATE teraticns and/or recommendstions__ _________________ ----------------------- -------------------------- ----------- - ------- - ------------------------------------------ ---------- ---------------------------------------- -------------------------------------------------------------------1--------- FINAL INSPECTION BY: v-__3N� / r - ----:--�'�------------------- �/ /o Date ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 5}oektan, California 814 North "C" Street # Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100