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i y / � APPLICATION FOR SANITATION PERMIT Permit No. ..-- -_ �-_._ (Complete in Duplicate) Date Issued _�3�s's ,ppli6a4ion s 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 C ounty Ordinance No 549- r JOB ADDRESS ANDATION-_______:- / % ---- fl.._ --" --------------------------------------------- ------ ----- Owner's Name ' Phone— -- .�.. . --------------------------- a,;, Address - ------•----------------•-------------------•------'--------------=----------=----------------------- - .. Contractor's Name---------- ---------------------------------------•------ Phone,, -- Installation will serve: Residence Apartment House ❑ Commercial ❑ NTrailer Court ❑ Motel ❑ Other El Number of living units: ___�-- Number of bedrooms .- Number of baths .l_-.mot size . d,, -f- ________________________ a Water Supply: Public system Community system ❑ Private ❑. Depth to Water'Ta - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ . Clay Loam [❑ Clay ❑ Adobe Hardpan ❑ k Previous Application Made: Yes [] Nog New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ; (No,septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance•from nearest well__________________Distance from foundation_____________ --.Material-----------------------------------. _________- No. of compartments-----------------------�Size---------------------------- ---Liquid depth------------------------ .'Capacity =:= Dispos Fi Distance from nearest well--------------- Distance from foundation-------------------.Distance to nearest lot line______i________. 'Y ----------Length of each line--------------- ------------- Width of trench---------------------------- Number of lines___._-______ Type of filter material-----------;,�:-------"Depth of filter material-----------------------Total length------.------------------------- --- Seepage Pit: Distance to nearest well_._7b----_.___'_Distance from undation____;__f__ ---.Distan� to nearest lot line___ _S Number of pits-------- ------------Lining rriaterial_ -- ---- ize: Diameter-----3-6. -----Depth---------- �---------- 5 1 Cesspool: Distance from`.nearest,well----------------- from foundation_._._._-_-----------.Lining materia ------ ____________`----:--------- Size': Dia . ' .. T -Liquid Capacity------------- ------gals meter------ ------------ Depth Privy:f Distance from nearest well----------------„--[-------`--------------------Distance from nearest building--------------------.---------- --------- ❑ _Distance-to nearest lot line-- --------------- --------------------- -------- --------------------------------------------------------------_-.----- - ' , Remod ing and/or repair g (describe):_..-- l ------•------------------------------------------------------- --- ---- . --------------- ----- •------------------ ---------------------------- I hereby certify that I hev prepar d this application an that the work will be done in accordance with San Joaquin Cottm*� ordinances, St laws,!and rues d :eg}tlatians the Sa oaqui acal Health District. t _ Owner and or-,Contract (Signed)---- ---- t }� ( } s g ------------------------------------------(r e) �� ' _ ' . : (Plot plan, showing s e lat,9ocatipfiof system in relationo wells, buildings, etc., can be plccon reverse�stde}. FOR DEPARTMENT USE ONLY I � � APPLICATION ACCEPTED BY DATE---------------y-- J :REVIEWED BY--------•----------------------------- - - DATE--- ---------- -------- ------------------------ BUILDING PERMIT ISSUED-------- -- -- - - DATE------------------------------------------------------------ .-_ Alterations and/or recomme ation :___-. - . . --- ---------- ___1_1 __.:: - ---- ------ FINAL INSPECTION BY:-------- _-- Date _ C --------` --------------------- ---------•--- ' SAN JOAQUIN LOCAL HEALTH'DISTRICT ,. 130 South American $treat 300 Wes+ Oak Street f32 Sycamore Street E14 North "C" Street Y. ia Manteca, California Tracy, California Stockfon, California Lodi, Californ 4 ES-9-2M ; Revised W-2100 f - �s�