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t { Permit No. .__.�_�_�..r APPLICATION FOR SANITATION PERMIT _ (Complete in Duplicate) Date issued __ - i Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I' This application is made incompliance with County Ordinance No. 549. I �r --•-------- •--------------- JOB ADDRESS MAP LOCATION -� � l /jxv Owners Name-----�-•---•----•-----•------ ---•--•---.. .. ----- ------ Phone Address----.- -� --�------•- ----- --------------------------------------•----------------------------------------------------- ' -------------•----- --------------------------------------------- Phone •-----•-------------- Contrector s Name_____ :*��"�:.®.---- -p Installation will serve: Residence / artment House ❑ Commercial ❑ Trailer Court ❑ Mote ❑ ------- Other ❑ Number of living units: _- ___ umber of bedrooms . -. Number of baths .-Z Lot size.__ -- �-f-�/• -• Water Supply: Public system Community system [IPrivate ❑ Depth to Wafter Table _ ~-_ ft. Character of sail toadp depth of 3 feet: Sand Gravel El Sandy Loam Clay Loam Clay ❑ Adobe E] Hardpan ❑ Previous Application Made: Yes E]: No New Construction: Yes No ❑ W I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted-if public sewer is available within 200 ffteeett.) rr� 1 t<f_ _ __—Materi I__�. -m-------- -.. Septi ank: Distance from nearest well 'Dis} elf noun coon_ -_ -- S,ize- Liquid dept q------- Capacity No. of compartments � a I �- ��• / �� �t'`t_-Dist Oce rom o�un anon----A-�Q-o------Distance to nearest lot in`e h �^ Disposal.Field: Distance from nearest we,l__._ __._.__ - Width of trench_.__. . Number of lines__________ ____ Length of each line-___________-_____ ,� r Type of filter material :.. t!6epth of filter material------j --_ ---.Total length------ - __0--------------------•---- . r,, Seepage Pit: T Distance to nearest well----------------------Distance from foundafiion_---______--___._-_.Distance to nearest lot Gne__.____-___._____ t --- ----- --- -Lining material------------- -------Size: Diameter-------------- --------Depth.------'-----------•------------- ❑ Number of pits.-- - Cesspool: Distance from nearest weil-----------------Distance from foundation-------------- ... Lining material_._____._--_______________-__-_____.. Size: Diameter..-- - - ------Depth----------------------------- ------Liquid Capacity----i-- ----------- gals. ❑ k Distance from nearest building Privy: Distance from nearest well--------- ----------------------- --------- 9 ----------------- ❑ Distance to nearest lot line------ ----- ---------------------------I----------- --------------•---•-------------------------------------------- ------ -- i + ------------------------••-•------•--•--------------.-_-------------•---•--------------------, Remodeling and/or repairing [deseribe)-------------------------------------------- --•------------------•---•--------------------•--------- - ;----------------------- { ;;.�.... r•--•• .. s } - • --- - ------- -- ----- •-- ----- ---•- - -•--- -- 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) — t --(Owner and/or Contractor) --------- - ---'----- By:------------------------------------ --• ------------------------ ----- ..------------------ ---------------(Title)---------- ------------------------------------ (Plot plan, showing 6%e of lot,location of system-in relation to wells, buildings, etc., can be placed on reverse side). 4 FOR DEPARTMENT USE ONLY/ APPLICATION ACCEPTED BY-- -. DATE -- -----•---------=-------------------------------- REVIEWED BY__!'------------------------- ----- ------------------------------- ---------------------------------------- DATEr`------------------------------------------------ BUILDING PERMIT ISSUED--------- - ----------- - DATE Alterations and/or' recommendations:---- �- ------- -------- -- 1/ i --------------------------•--------•------ - --------- � av _ -- .Vii' - - ----- ---------------- ------------ -------------------- - 1 Date V L4' Y"S FINAL>INSPECTION BY:_.___--- -'--------------------------------- ------------------------ --------------------------------- ------- -- ---•----------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street 1 $tocktan, California Lodi, California Manteca, California Tracy, California • �.ES 9-2M 145445 ATWCOD 12-54 (.