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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ w :._w.. . , _ Date Issued /9:=$_.7- 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 C unty rdinance No. 549. JOB ADDRESS ANII -O t1TION______ Owner's Name__± = - .--------- ---- . . - Address--------- Contractor's c (f1 Phone P)----- ' / v on Tactor s Name_____: '___ Installation will serve: Residence Apartment House• ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _;;;1=un er of bedrooms ---I__• Number of baths __ ____ Lot size __<,: l ------ --------------- ater Supply: Public.system' ify system0 Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑. No New Construction: Yes ['No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: x (No septic tanW or cesspool permitted if publi lF sewer is available within 200 feet.) Septic ank: Distance from nearesr wellC550_ { istance fro foun ion__- - ori I ________ __ No. of compartments_------------ Size_ e� �] l = x Liquid depth hL-----_--- ---Capacity_. Dispos Field: Distance from nearest eii _ i ce from foundafiion_IP_t-1 P.-I""Distance to nearest lot line___ N mbar of.lines_________-_- t.- ----- #,Length of each line______ french-.---/---- - + Yp g'l t ._lf_.Width of trench T e of filter materi 1 - T_ --- _---Depth of filter material--- - g Total len th---------- v-------'----••--------- Seepage Pith Distance fo"nearrest well""`_„""•- 'Distance from foundation______.____- Distance to nearest lot line----------------- tj ❑ Number of pits-.#-------------------Lining material-----------------------Size: Diameter--------------- ._t— --------Depth--------------------------------- 6 Cesspool; Distance from nearest well-----------------Distance from foundatio Size; Diameter____- - _ n'_-___---------------Lining material-------------------------------------- ❑ ___ __ _ .---------Depth----- -------- -----------------------------------Liquid Capacity . --------- ------ gals. Privy:i Distance from nearest well------------------ _:_____ --_--------_ -Distance from neare' '' 9 buildin . _ s ❑ `� Distance•fo'nearesf,f6f_line - ------------------- Re odek—g and/or repairing {descrilJ :-__ c, ,y ----------•---------------------•- G ------•--------•----------- - ---- --------------------------------------•----------•--------------------------------------------------------------------------------------------------- -------------------------------- - I hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat a s rules and regulations of the San Joaquin Local Health District. (Signed)----- ---------------------------- ----------------------------------------------------------------------------(Owner and/or Contractor) gY= - - 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 APPLICATION ACCEPTED BY _-_ DAT -r�– REVIEWED i3Y- - -- - • - - � ---'--- ------------- ----------•----------------------�- ----------------------------------------------------------------- DATE----- BUILDING PERMIT ISSUED ------------------------------------------------------------ _- ----- DATE-------- Alterations and/or_recommendations: � `------------------- -----------•-------- ----------- ` -- 1 ------- --•-------- FINAL INSPECTION -BY:.:- -- - ----•--=---------------- Date'= 7_-- ----------- ------------:------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 11 130 South American Street 300 West Oak Street 132 Sycamore Street 5totkton, California Bl4 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-21W