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1, F APPLICATION FOR SANITATION PERMIT Permit No. ---------- •, (Complete in Duplicate) -'f S Date issued ___3__.____�_-._ Applica{ion is hereby made to the Sari 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. I � � •- JOB ADDRESS AND LOCATION-----------� 1*1/1---------- 1-6-`�-�------- / -/� .�- -----------------------------------------------_------------------------- Owner's Name------------- -------- , --t n-------- r#"5--' - - - --------------------------- ------------- Phone----- Address-----------------------------------------------------=-------------------- ' --•----------------• -------------------------------- Contractor's Name---------------------------------- ------------S `'� '---------------------------------------= ---------------- Phone---------------------------------- f � Installation will serve: Residence [ Apartment House ❑ Commercial [-] Trailer Court E] Motel E] Other ❑ Number of living units: ________ Number of bedrooms _-2___ Number of baths -------- Lot size ____--_-5.-_-_._ ______________________________._____ Water-Supply: Public system ❑ Community system .Iq Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel [-ISandy Loam ElClay Loam ElClay ElAdobeo Hardpan E]Previous Application Made: Yes F1No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--------- _______Distance from foundation----------------_--.Material_________________________________________________ ❑ No. of compartments--------------------`--Size-------•------------------------Liquid depth----------------- --------Capacity----------------------- Disposal Field: Distance from nearest wefi-----------------Distance from foundation--------------------Distance to nearest lot line__-.____._______- ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench.------ -------------------•------- Type of filter material-------------------------Depth of filter material--- Total length------------------------------------------ \ : I .Seepage Pit: Distance to nearest well---------------------:Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits -------------------Lining mate rial-----------------------Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance from nearest well_______________-Distance from foundation____________________Lining material------------------------------------- ❑' Size: Diameter_ sI------------------- -----------Depth_ -------------------------------------------------Li quid Capacity-------------`--------------------------------gals. r Privy:` Distance from nearest well------ ------------NO---------------------Distance from nearest building------------ _____-_________------------------. Distanceto nearest lot line-----------------------------1'D--------------------------------------------------------------•------------------- Remodelingand/or repairing (describe):-------- ------------------------------------------=--•--------------------------------- •----- -----•--------------------•--------------•-------------- 'I ----------------------------------------- --- ------- -------------=-------------------------=----------------------- ------------------------------- ----------=---------------------------t----------------------- --•------------------------------------••---------------•••----------- I hereby certify that I have prepared this application.and fhat-the'woikwrili�be done in accordance with San Joaquin County � ordinances, State laws,-a d rules and regulations of the San Joaquin Local Health District. r ----------------- ------------------------------------------------------- S� -- (Signed) -_-(Owner and/or Contractor) ( .g )-- - gY=-------------------- (------------------- ---- -------------------------- -----------------------------------------------------(Title)----•----------------------------------------------------------- (Plot plan, showing sizer of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). s L FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ( --- --=----------------------------- DATE -,. - J f f REVIEWED BY-------------------------------------:- ------------------------------v.-___--------------- ----------- --------- DATE-----------�--------•--------------•-------------------- BUILDINGPERMIT ISSUED------- -------=---------------------------- ----------•--------------------------------------------- DATE--------------------=----------------- --------------------- Alterationsand/or recommendationsi----------------------------------------- ---------------_------------------- .-------------------------------------------------------------------------- ••----------_----- ------------------------------------------------------------------------ 't d _ f FINALINSPECTION BY:-- ----------------- Date_------------------- -------------------------- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California ES-9-»2M ; IRevised W-2100 r