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,yr x APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) l/ Date Issued ___.,!z__ Appliceion 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 om lliia�ce with County Ordinance No. 549. JOBADDRESS LOCATION. - ------ ------ ----------------- ---------------------------------------------------------------------- Owner's Name ---- ---- - --------------------------------------------------------------- Phone----------------------•------------- Address--------------------•------ -------- ------------ Contractor's Name____ ___ _ ___ _ ________0_ Phone.-%r Installation will serve: Residence �artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/-___ Number of bedrooms Number of baths __4•=Lof size ____J_?Q__ Water Supply: Public system ❑ Community system ❑ Private [g--Depth to Water Tablej,0_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E❑ Sandy Loam ❑ Clay Loam ❑ Clay 0 Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 42--*ew Construction: Yes ❑ No --- TYPE OF INSTALLATION AND SPECIFICATIONS: ,(No septic tank or cesspool permitted if public sewer is available within 200 feet.) f Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material--_-______-_-________----________________.-____. y No. of compartments--------------------------Size-----------------------------.._Liquid depth--------------------------Capacity---------- ----------- isposal Field: Distance from nearest we€f-----------------Distance from foundation--------------------Distance to nearest lot line---..________._. Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-------•---------------Total length----------------------------•--_----- - •- See age Pit: Distance to nearest well-.1 19 l-----Distance rom foundation_-. Q __._.Distance to nearest lot line-___ R Number of pits-------.----------Lining material_, ------Size: Diameter__---�T----� j____Depth_-, 'f________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.___--__________________-_ _- V ❑ Size: Diameter-------------------------------------Depth---------------------------•-----------------------Liquid Capacity---------------------------- Is. \ Privy: Disfance from nearest well ___________________--------___________.___.-----Distance from nearest building____________------___---_--_---_� ❑ Distance to nearest lot line-----------------------------------------------------•----.... t Remodeling and/or repairing (describe]: ---------------•- ------------- ---•-•--------------••---•--------------------..-.............. ------------------- -•--------------••---•-------•-----------------..----------------•----------------••----- --------------------"---------- ------------------------------------ ----------------••---•-----------------------------------------------------------------�___.---------------•-•----•-----------------------------••- --- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin Cou ty ordinances, St law j and rgl" and re lations of the Sart Joaquin Local Health District. , (Signed) -- By:.•.- ------- + + ----------•--------------------------------------•----(rifle) ------- --------------- (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------- REVIEWEDBY-------------------------------------- - - ----- -- ---------------- --------------------------------------------------- DATE-------- •• BUILDING PERMIT ISSUED------------------ ----- ------ -----•---- DATE------------------ ------- ------------------------------------------------ � -- ` � - --•-- Alterations and/or recommendations:_------.__.._ -• ------------------------- ---------� -----•-•-------------------------------------------•-•-----....------------------------------ -----------------------------•------------------ --------------•---------------••--------------------------------------.-- -------- - ---------------•------------ -------------------•-----------------------------------------------••------------•--------- FINAL INSPECTION BY:-------- � : ---------- Date------- - -- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Stree4 814 North "C" Sfreet Stockfon, California Lodi, California Manteca, California Tracy, California ES-9-2M ' Revised W-2100