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APPLICATION FOR SANITATION PERMIT Permit No. y 1� (Complete in Duplicate) :Date lssuec/d_-_/'50(-61 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 O dinance No. 549. JOB ADDRESS AND LOCATION_______ ______t u_�___ -------- --- -----a- ---- Owner's Name........... . = -- ---- ------------- - -- -- - ------ Phone----------------------------------- Address---------------� F��°� ��- � a,t__. Contractor's NameQ� -j.. �s `v I ----------------------- Installation will serve: Residences ❑ Apartment House ❑ Commercial E] Trailer Court E] Motel ❑y /Other ❑ ,Number of living units: __1__-_ Number of bedrooms -__ Number of baths j--- Lot size _/---�f<-�X---/__ _ _______________ Water Supply: Public system Community system '❑ Private E] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lo;'PNc Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ Previous Application Made: Yes No New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tanks Distance from nearest well------------------Distance from foundation--------------------Material ______-_______---___._______________- ❑ /[ No. of compartments-•---- -------------------Size--------------------- •---------Liquid depth--------------------------Capacity----------------------- Disposal Feld: Distance from nearest well------------------Distance from foundat-on__ - ______.Distance to nearest lot line__________ Number of lines---------/__________ _ Length of ch line_-_ _ ------- is of trench_. ,�y� Type of filter material__.-/(Q---- p r �r--------------------- ----Det of er-na�#.e al-----�-[�----------Total length----�.---------------------------------- Seepage --------- -------------Seepage Pit: Distance to nearest well______________________bis an fou ion__ jo••__-____.Dista ce to nearest lot li e _____ , ,[A� Number of pits________________ __Lining mat rfal_ e: iameter__._�_____-___---.Depth----_�'______ .-_ - ----------- Cesspool: Distance from nearest well________________Di lance m-f un ation--------------------Lining material------------------------------------- El _____.---- ___________---_________❑ Size: Diameter--------------------------------------Dep - -----------------------------------------------Liquid Capacity----------------------------ga Privy: Distance from nearest well________ _______-_--__----____-------Dista nce from nearest building_____-_.________----________:____.____. ❑ Distance to nearest lot line------------- ----------------------------------------------------------------------------------------------- ,f A/Remodeling 1! """ Remodeling and/or repairing (describe) ------ -----------------� •-------- ----------------------------------------•------------------------------•- •---•--- _t -------------•--------------------------------------••-------------•--------•----------------------------------------- ------------------------------------------------------------------------------------------------•---- ----------------------------------------------------------•--------------------------------------------- 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, and ruh and regulations of the San •.------- --- _ W*1Z - Joaqu- Local Health District. (Signed) ----- ---------- -------------------- e ----- -(Owner and/or Contractor) By:--- ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reve side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------------------------- ------------ DATE- - --------------------- ----• ------------ DATE--- -_-'� ------------------:---------------- BU LID NG PERMIT ISSUED-------------------- --- ------------ --------- -------- -----------=------- - DATE----------- — - Alterations and/or recommendations. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------- ------ - ----- -- -------------------------------------------------- FINAL ----------------- ---------- FINAL INSPECTION BY: - - -- --- - -- - -- - -------------------- Date-------- AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100