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APPLICATION FOR SANITATION PERMIT Permit No. ._./f./f (Complete in Duplicate) Date Issued -__�l_ ' ,1, Application is hereby made to the San Joaquin Local Health District for a permit o construct and in tall the work her scribed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO ATION___ ��:___t`.fct-s� c .. _*r __ ____p��_ _ _ ---------------------------r - Owner's Name = * -------------------------------------------- Phone ------------ Address---------_ ------ C� occtt- -�---,,-Q------•-•••-_.....---- ---------------------•-- --------------------- / Contractor's Name-- ___t`I _l�l-� .,`` (,�',..�1____ -s----------------------- Phone_ ._.� � (? Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms _1_____ Number of baths j____ Lot size -------- -____________________•__ Water Supply: Public system ❑ Community system ❑ Private jr--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,9�_No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS- 0'_ (No septic tank or'cesspool permitted if public?? .4s available within 200 feet.) .. Septic T Distance from nearest well'!____Distance from foundatiorkc:i.l ._____.___..Mat rial____------___ ____ . B No. of compartments-1 __ .(* I uid d pth__ _h._________Capacity------Y -----__- Disposal field: Distance from nearest well_!W 7._Dista ce from fou _��----Distance to nearest lot line... ___. Number of lines____________.__�t____________Length of each lin _ ______________Width of trench----Clj_e! Type of filter material�?_4_llrie--_____Depth of filter ma .$!�__�- Notal length.___-_8Q`_..____________________ Seepage Pit: Distance to nearest well-------------------___Distance from foundation. ................... Distance to nearest lot line----------------- El 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 line----------------------------------------------- ---------------------------------------------------------------------------------------------- Remodeling and/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 "v ordinances, S laws, and rulej and regula 'ons of a San J aquin Local Health District. Q (Signed)------ _ U---- -�CTA_ -- ----- ---- --------------------------------------------ner"e�wkjia�Contractor) By:------------------------------------------------------------------------------------- --- -------- =----------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation wells, buildi gs, etc., can be placed on reverse side). FOR DEP RTMENT US ONLY APPLICATION ACCEPTED BY.----`TtiR-®`------ -------------------•-------------------------------- ----------- DATE--------T 'Z-Af!n- ------------------ -- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE--------------- ------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------ --------------- DATE------------------------------------------------------------ Alterations and/or recommendations--------------------------------------------------- --••-------------------------------------------------------------------------------------------------------- - --- --------------- ----- - -------------------- ---- -- -------------------- -------- ---- ----- -- 7nia -- ----- --- -- FINAL INSPECTION BY:-------- ____ --------___ ��lr / Date__--------- -__ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North Stockton, California Lodi, California Manteca, California Tracy, C ES-9-2M , Revisea 1.57 F.P.CO.