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APPLICATION FOR SANITATION PERMIT Permit No. ........................ (Complefe in Duplicate) !'1 /,y C 1 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[e o. 549. JOB ADDRESS AND LOCATION.-----_ - ------ ----V8 - - -- -- -- -- ------------------------ Owner's Name------------ ! e .. .. ------------------------ /� h�--- ------------------- ----- Phone- Address---------------- /�? 17Zr,- .CS�d�C7 TIC Contractor's Name----•---------------------•-•---•---------------- = -- ------------------------------------------------------•--•-•-- Phone----------------------------------- Installation will serve: Residence X Apartment House ❑ Commercial. ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1__. Number of bedrooms --Y.- Number of baths _--/-_- Lot size -----7,--_X___��3 _-_---------------- Water Supply: Public system ❑ Community system El Private, . Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobea Hardpan ❑ Previous Application Made: Yes J No ❑ New Construction: Yes X 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_____--Distance from foundation---- O-.--_-.Material_______ . � ------------------------------------- No. ____________.____ _..__-_-._-___. No. of compartments------- x -------- .............CapacityJ&r Disposal Field: Distance from nea,�r/�Ist weli.__!4�rO___Distance from foundation-------- to nearest lot line----_-.---- Number of lines___ _________________________ Length of each line-------_4.S____._-•---- Width of trench---------2- �._ -__-_____ Type of filter material --Depth of filter material___...-.-/��----Total length---.-_-.-_-------_----ZeF -__--.- Seepage pit: Distance to nearest well--------------------_Distance from foundation------------------- Distance to nearest lot line----------------- 4 ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------------.---.-----Depth......------------------------ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_-------_---.--------__---_----_._-. ❑ Size: Diameter--------------------------- -------- -Depth_------------- -------------------------------------Liquid Capacity----------------------------gals Privy: Distance from nearest well-... ----------------------------------Distance from nearest building-_--...._____---_-_--___-.._--_-__------_. ❑ Distance to nearest lot ling. -----------k----------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)--------- - ----------- --------------- ------------------------------------------------ -•-••-• ........ --------------------------------•-------- --- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------•----------------------------•-------------------------------------------------------------------------------------------------- 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 regulations of the San Joaquin Local Health District. f t [Signed.) - �' �`� =1..- '' 'r----- -------------------------- --------------------(Owner and/or Contractor) ------------------------------------------------------------------------------------- (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----------------------- - - -------------------------------.._..-----••------------- DATE------- REVIEWED BY------------------------------------------ DATf BUILDING PI RMIT ISSUED - --------- ---------------------------------------------------------- DATE------ •---------------- Alterations and/or recommendations-----------------------------------------------------------•-----------------------------•-----•-------------•----------...----------------------------------- ------------------------------- ------------------------------------------------------------------- -------------••--•-•--------------------- -------------------------------------------------------------------------•--- ..,ra -------------------•----------------------------------------------------- ---•-------------------------------------------------- ------------------------------------------- ----------------------------------------------- FINAL INSPECTION BY:----- ---------------- --- - --- ----------- Date---------------------1. 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 J ES-9-2M 145446 ATWDDP 1Z-54