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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued .-5 -- Applica+ion 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 L. AT �� -_ Owner's Name_ i--•-• ' --- ------ Phone__. , - -•--- Address� : �'� -••-----• ------- -- Contractor's Name------•---------- Phone Installation will serve: Residence x Apartment House ❑ Commercial [I Trailer Court ❑ Motelr❑ Other P Number of living units: _ � Number of bedrooms _A. Number of baths .__I-- Lot size ------ Water Supply: Public systerll Community system E] Private E] Depth to Water Table' Character of soil to a depth of feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan E]Previous Application Made: Yes E] NOO New Construction: Yes � No F1 TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 5 tic Tan Distance from nearest well_________________Distance from foundation-------------------.Material ___________.__.__.___..______.___._______-----•- No. of compartments______________ ----- ---Size----------------------------- --Liquid depth_------�------------------Capacity----- isposal ielc}: Distance from nearest well---------------- -Distance from foundation--------------------Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line------------------- -------Width of trench Type of filter material-------------------------Depth of filter material--.-------------- ----Total length---.-------------------------- Seepage it: Distance to nearest well_ '_____Distance from fndatio Distance to nearest lot line_ _______ Number of p - -_ its.__.____-__.____._Lining material Size: Di eter__-.: De t� r --.--- p n ----- ill ---- esspooL Distance from nearest well El from foundation---.-.____._ _._-_ Lining materiaL_-----.--------_____ -----_---. \ El Size: Diameter--------- -------------- ----- ----Depth------------------------------------------ - _--------Liquid Capacity-- ------------------------gals. Privy: Distance from nearest well_____.__._-----_------ ------ ------------------Distance from nearest building ❑ Distance to nearest lot fine-------------------------------------------- Remodelin re airing (describe):--- - ---- - --------- - -------- -- - ----- - ---- ----- ----------- ------ describe :--- ---------.- - -------------------------------- --------- ---------•------------------•--•---------------------------------•-------------------------------•----------•------•------•---------------- -- --- --- --- ---------- ---- - -------- --------•-------------------------------•--------•----------------------------------I---------------------------------------------- -------------•--------•-•--------------•----------•--------•----------------------- ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St aws, ides and r ulations of the San Joaquin Local Health District. (Sighed)--------- -- - - - '- ------j•- --- --- -------------- ---------------- ---------- --- -- -----(Owner r Confractor) By:-----------_---- •----------------------------- ------- Title _ { ) (Plot plan, showing size of lot, location of system in relation fo wells, buildings, efc., can be placed on reverse sid FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- DATE _ REVIEWED BY------------------- -- tr ----------- ---------- -----------/------ DATE I -------------------------------------------- BUILDING PERMIT ISSUED--------------- f Alterations and/or �m L7 ions.. ,'---.-.- - DATE --------------- 5 ---- -------- --------------•-------- -- ---------------- Ike i 4 - - ------ -------------------------- - ---- ----- ----- -- --------------------------------------- FINAL INSPECTION BY:--C-- Date. 6O 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 ES-9 145446 ATWonn