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APPLICAT)ON FOR SANITATION PERMIT-- - Permit No. _c _ __._ __.. (Complete in Duplicate) /� 3 1 K Date Issuedpplication is hereby made to the oaquin Local Health District for a permit to construct,and install the work herein described. This application is made in complia,c with County Ordinance No. 549. -------------------- Owner's -------------------------------------------------------- JOB ADDRESS AND LOCATION.------------ --------- ---------------- Owner's Name-------------•----------------- ---------- --• ---- --------------------------------------------- Phone------------------------------------ Address------- ------------------- ---------------------------------------------- Contractors Name----------------- ------------------------ L----------------�--------------------------- Phone---•-------- ------ . �� Installation will serve: Residence Apartment House ❑ Commercial ❑ Tr/ailer Court ❑ Motel ❑ Other ❑ Number of living units: __r___ Number of bedrooms r,�_�_ `Number of baths [------- Lot size ______4-p............ . ------------------- a 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 ❑ Clay ❑ Adobe r pan ❑ Previous Application Made: Yes ❑ No It. 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__4�Iz_Pisfance from foundation__/_C!__.-------Material--- _._ � ________________ No. of compartments ------- --------Size----__ _-- _- __ Liquid depth---------- ---------------Capacity__ -- A Disposal Field: Distance from nearest we I !�` -� Distance from foundation_____________.____.Distance to nearest lot line___--s� ..- Number of lines________________-_Length of each line:- .a° I---.Width of french-------- Type of filter material_]-- _ .Depth of filter material___ .�_ _��______--Total length---.__f_..�__._ ._ _______________� Seepage Pit: Distance to nearest well----------------------Distance from foundation__________.._____-.Distance to nearest lot line__.______.______. I ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------.-- -------Depth-----------.------------------:-- .i Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material__�-------------------------_-.______ 171Size: Diameter- -----------------------------------Depth----------------------------------------------------Liquid Capacity'----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------------- - . ❑ Distance to'nearest lot line--------------Y--------------------------------•----------------------•------------------------------`----:-------------•-- Remode4ing and/or repairing (describe):----------------------------- ---------------•-••----------------------------------------------------------- ------------------------------------------ (( i r ` I ----------------------------- ------------------------------------------------------------------------------------------- i 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 rules and re ulations of the San Joaquin Local Health District. 1 (Signed)_-__-- -- ------------ (Title)--. ) [Owner and/or Contractor) - ) By:---------------••-•----------------------------...--------------------------------------------------------------------------------- Titl)- ----------------------------- •-- [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be laced on reverse side). f w FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --= - ------------------------------------------- DATE-------- -3- --3-------- REVIEWEDBY------- --------------------------------- ------------------------ ------------------------------------------ - DATE_---------------------------------------------------------•- 4. . � . '1-` - DATE �BUILDING PERMIT ISSUED------------- --- ----------------- ---- ------- ---=--= ------- . r tAlterations an or recommendations -, t y -- --- • - " _ n--�- - r ate D DIN I NS'?CBCT BY - 1-�, ��= ---f�-------Z ---�- -- ------------------------------ SAN JOAQUIN LOCAL HEALTH D157RIC x BG+h A ' n : West Oak Street 132 Sycamore Street 814 forth "C" Street ocfcfCeeicalifornia Str 300 Lodi, California Manteca, C4lifornia Tracy, California s E. 9-2M io-52 Revised W-2100