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APPLICATION FOR SANITATION PERMIT Permit No. d-- ' (Complete in Duplicate) Date Issued,/_O,.1 r 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 LOC,-)TION_.Ja I--_ �_- / ' ------ ------ ----------- ----------------------------------------------------------- Address........---- -------------------------- Phone--- -- q ---------- A ----------------------I---------------------- Contractor's Name----- -----------• -----------••--------------•------•---•-•------ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court C] Motel_ ❑ Other ❑ ,..�]f Number of living units: __- _-- Number of bedrooms ___� Number o baths __�-__ Lot size _-_� {/____ r / Water Supply: Public system ❑ Community system -r_2-0----- Y Y Private Depth to Water,Table _ ft, Character of soil to a depth of 3 feet: Sand)D Gravel ❑ Sandy Loam Clay Loam Clay ❑ Adobe El Hardpan ❑ Previous Application Made: Yes ❑ No 0' New Construction: Yes 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 --___ ` ❑ No. of compartments--------- --- Material--------------------------- f---_Size -- ----- -- --------•Liquid de h - Dispos Field: Distance from nearest w IlQ-_-_---Distance from foundation-- Capacity____ -_ __� ' Number of lines------------ �s-_ ---_ Length of each line--------- 19r__----Distance to nearest lot lin Type of filter materia >�� Width of trench---- --r -- --------- ------- - - epth of filter material_______------------Total lengfh----------/0. --------------------- Seepage Pit: Distance to nearest well---------------------- � __._--_____Distance from foundation_______________ ❑ Number of pits__------------------- --.-.Distance to nearest lot line_________________ ------Lining material------------------ ---Size: Diameter------------------ - ' - - Depth- ------ --------------- - esspoo: Distance from nearest well-----------------Distance from foundation--------------------Lining material I--] Size: Diameter--------------------------------------Depth------ -- ----- gal -- --- - - -- --------Liquid CapacitY-------------- _- - -----------gals. Privy: Distance from nearest well------- Distance from nearest buildin ❑ Distance to nearest lot line_ g Remodeiin d oirepairi (describef:____ _ _-- ----- - . ------------- ---- -- _ ----------------- I - - -------- -------- - -------- --------------------------------------------- ------ ------------- ------------------•-------------------------------------------------------------------------------------------------------.------------------------------------------ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, a rules and regulations of the San Joaquin Local Health District. (Signed)-------- ----- / 1 --- -------------------------------------------------------------------------------------------- (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 _._ ------------------ ------------------------------------------ REVIEWED BY--------- -------- ------ --------- DATE--- - -- -- --------------------------------------------- ! k BUILDING PERMIT ISSUED__. --------- DATE----- ----------------------- --------------------------- Alterations and/or recommendations------------------------ DATE_----__--_ -------------------------------- -------------------- - - - ----------- FINAL INSPECTION BY: p ff SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stree+ Sock}on, California 132 Sycamore Street 814 North "C" Lodi, California Scree} Manteca, California Tracy, California ES--9-2M 8-51 Revised W-2100