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i APPLICATION FOR SANITATION PERMIT Permit No.�... ........::.. � � f (Complete in Duplicate) Date Issued//_._/_Q•__"_. ; Applica+ion 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 Ordina ce 549. JOB ADDRESSA � LCCATIO - -. � k Owner's Na , ---- ------------------ Phone--- Address ------ - - --- ----- ----------------- -------------- Contractor's Name------=------------- ----- - �-_ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ - Number of living units: __/-_ Number of bedrooms-Z' ._ Number of baths _/___ Lot size Qf�� .1 _________________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water'Table _e ft. ,Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑",Cay ❑` Ado Hardpan Hardpan ❑ Previous Application Made: Yes ❑ N6X) New Construction: Ye No ❑ { x - t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f 1 Septic Tank: Distance from nearest well_ --- ♦ ` _ Distance, fromfounclVion_ �_____.�____i.Mt a�eri I __-______. Nco art ! Liquid depth ----�.___-_-__Cahacs#Y ` Dis osal Field: Niumberof lines----/arest well. �r Distance from foundation_��J_�_-_.._.Qistance to nearest lot line-------`_)__._ p r .....Length of each line-------.S0_ _� __--.Width of trench--------le- ------------------ Type ----------------- T e of filter materia ___ Depth of filter material____ _ _____ ____ Yp - -_ --- !� Total length-----------��J------...•-- -•--------- / ' / Seepage Pit: Distance to nearest well- _ ,_ -___Distance om dation__,1 .-F.__. Dist�nce #opepa+�st lot ----- __--- V1Number of pits--- Linin maters Size: Diameter___ / 'Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.__.____.______________--_.____-__ - - - ,- _Sizea4Diameter__ - . -,t ..._ =Depth gats. .. Privy: Distance from nearest well__________________________________________._.__Distance from nearest buildings:..-_---___._______________.________ . ❑ Distance to nearest lot line______________________ ___ = t •----------------------------------------- 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, Stat ws, and les nd regulations of the San Joaquin Local Health District. (Signed) T ------------------------------------- wner a ntractor By----------------------- •- - (Title)- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pla on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------------------------------------- ------ DATE .-----------------------------------•-------------- REVIEWEDBY--------------------- ---- - -- ------ -------------------------------------------------------------- --------- DATE- BUILDING PERMIT ISSUED--------------------------------------------------•------------------------------------------------ DATE--------- and/or recommendations:------- ------ ----------------------------------------------------------------------------------------------•-------- ----- _________________________________________________________________________________________________________________________________________________________________••_--.____________.______--_-._____________--•-•---__________ i _______-_-. _________-_____.__ _-_-.__.._____-._-..._ .-____________________ti_ _ ________________________________________________._.-_____----__-__________--------__----_._.------_-.---__.._..__.__-____-..-____._______._____ _..______.._____.__._.-___-__________-___.___.______._________ _____________ FINAL INSPECTION BY ------------------------------ --------- Date----.------------f`--- SAN JOAQUIN LOCAL HEALTH DISTRICT ; 130 South American Street 300 West Oak Street 132 Sycamore Street— 14,Ni0+h "C',' Stree+ ; S+ockfon, California Lodi, California Mani; ce,•Ceiifomie ° Tracy, California ' California M ES-9-2M Revised W-2100 A 71,; $r