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APPLICATION FOR SANITATION PERMIT Permit No. __ �_�__✓_ _- "' (Complete in Duplicate) / 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 No. 549. JOB ADDRESS AND LOCATION___/ : Owner's Name--- --------------------- ---------.. Phone Address_------- ------------------------------------- ------ --- -------------------------------------------r k � ---- -..-------- -- --la-- -- -- 14?4ConeContractor's Name Installation will serve: Residence ❑ Apartment House ❑ Commercial E] Trailer Court ❑ . Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths _ . Lot size -------AXjZj&,,w-------------__------_ Water Supply: Public system ❑ Community system ❑ Private, Depth to Water Table _S'o ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 4 Clay Loam E] Clay E] Adobe E] Hardpan E]Previous Application Made: Yes 0 Not New Construction: Yes,v No E] FHA/VA: Yes [] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available wifhin 200 feet.) Sepfic Tank: Distance from nearest well___-!�_q�+___Distance from foundation___ ---- �_-____.__.Material__-_----- a -__---_ No. of compartments - _ - ------- _ /-3- . q 9Liquid depth_-__ _ ___ -- Caci �7� l� p ---------- --- -Size ` P tY---- Disposal Field: Distance from nearest well_- n_7�'----Distance from foundation__ 9_'_-------Distance to nearest lot line--47-* Number of lines______-- __ Length of each line ►5�0----------------_Width of trench--- _. Type of filter materia __ __ Depth of filter material---it"--_------Total length----S'4_____ --------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line______._-_____.__ ❑ Number of pits---------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_________.__.-_ El Size: Diameter------------------ --------------------Depth----------------------------------------------------Liquid Capacity------------------------ --gals. Privy: Distance from nearest weli-------------------_-----------------------------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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)________ _ __ (9� Owner and/or Contractor) -- -By----- - ' ---------- -- 1k----- ---------------------•--------------------- ------(Title)---- Plot plan, showing size of 6lo+ ocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY �1( APPLICATION ACCEPTED BY__-- -- - -- ------- =-- -------------------------------- -- ----------------------------- REVIEW ED BY -------------------------------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED--------------------------------------------------------------------- - ----------------------- DATE Alterations and/or recommendations:------- --- .__._-________. --------------------------------------------------------------------------•-------_-------•------------------------------------------------- --------- -------------------•------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- FINAL INSPECTION BY:-art - -------------------------•----- Date... - -L, 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-9-2 M Revised 1.57 F.P.CO.