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APPLICATION FOR SANITATION PERMIT Permit No. __�17 --- (Complete in Duplica+e) 6 �S \� Date Issued -----__ _.___/S � ��describe Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work rein This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND OCATION.. 7-------A ------� ----------------------------------------------•--------------- ----------------------------y- Owner's Name__________ _ `--------------- ----------------------------------CPhone -., _. _ U-.. Address---------------� �.�------- Contractor's Name----------1 12 --------- ----------------------------------------------------------------------------- Phone---{ r Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 7 � r Number of living units: __/__ Number of bedrooms .2-_ Number f baths /__ -ALot size .-1�__,--X--f,-.Q----------------------- ______ Water Supply: Public system ❑ Community system E] Private ; Depth to Water Table /0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ff"'Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes <o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well___ __ ._ Distan e fro dation---- Mat grial� 4a . _ __ 210No. of compartments---- --------------�i7 e-- _ _ _- ------------- Liquid depth------ 0 ----------Capacity---Disposa field: Distance from nearest well-_ -_Q------Length ante"fromr u��a' on--- �--_----.Distance to nearest lot line__-__---_- ff" Number of lines__________________ ___. ._Length of each line_________ -d®-_ _---._- Width of trench..__e �-----..-----_.--_- Type of filter material-- _______ ___Qepth of filter material___.._-l_ ��_-_.-Total length------ Pit: Distance to nearest well----------------------Distance from foundation_.----------.------.Distance to nearest lot line----------------- Ell Number of pits----------------------Lining material-----------------------Size: Diameter----.------------------Deptn--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining material------------------------------------- El 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 ordinances, State laws and rules and regulations of the San Joaquin Local Health District. -------- (Signed) ---------------------------------- ( and/or Contractor) BY:-----------------1 -- ------------------------------------------------------------(Ti+le)----- -- ---- -- ----------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- -- --- -- ---• -- ---- ---------------•------------------ ----- DATE --------- - REVIEWED BY ----------------------- ------ DATE --- -------------- 1 BUILDING PERMIT ISSUED._-.---•--------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:.---------------------------------------------------------------------------------------------------•-----------------•-•---------------•-------------------- ------------------------------------------------•------•------------------------------•--- --------------------------------------------------------------•-------------------....-------------------------------------.... ------------------------------ •----------- •------•-----------------------------------------------------------------------------------------------------------------------------•--------------...----------------.------ ---------------------------------------------------- -----------•----------------------------------------------------------------------------- -•-------•------------------------------------------------------------------- FINAL INSPECTION BY.--.--,--.- -- ----- /fr ----------------------------- date---------�--f----r- -- -� .+� -----------------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stacktori, Califordia Lodi, California Manteca, California Tracy, California ES-4-2M 10-52 Revised W-2100