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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Applicaa•ion is hereby made to the San Joaquin Local Health District for Date Issued�G'_ ��,�`~� This application is made in compliance with County Ordinance No. 549. T a permit to construct and install the work herein described. JOB ADDRESS AND LOCATION_._____- _- Q - Owner's Name = = - _ ------------ -------- Address - .�.! ----- Phone----� a --------------- ---•--Contractor's NameSQA=/ - Installation will serve: Residence �- ❑ LL'' Apartment House Commercial Number of living units: - " ❑ Trailer Court ❑ Motel ❑ Other E] --_-_ Number of bedrooms __y Number of baths ._ ____ Water'Supply: Publics stem Lot size _--_ _Q- �` / ,r� Y [] Communit system ....................Y ❑ Private ❑ Depth to Water Table ___ ft. Character of soil to a depth of 3 feet: Sand ❑ Grave! C] Sandy Loam ❑ . ClayLoam Previous Application Made: Yes E]'E] No ❑ New Construction:._Yes [I No Clay ElAdobe 54 Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank Por cesspool permitted if public sewer is available within 200 feet,) Septic Tai1Knk- VS, Distance from nearest welt-----------------Distance from foundation_____________ ,.� , No. of compartments-___-.._-.__ Material____------_ v ------------ Size-------------- ------------------------------------ Disposal Liquid depth------------ _Capacity Field: Distance from nearest well._.--_- _--_.Disfianee from foundation--------------------Distance to nearest lot fine____ ❑> �lsr�n�G Number of lines-- 3i --------Length..of each line------------------------------ --•----• R� Type or filter material----_---------- Depth'of filter material_ Width of trench--------------- - Seepage Pit: Distance to rieares-::well-- - - ---------------------Total length--:------------------------------------- N01q,E_----Distance from foundation___IV_,----•.Distance to nearest lot in /_ Number of pits _ _-- --Lining material---8_Rl_+" ----Size: Diameter---- `� ' ------- Cesspool: I 1 -------------Depth---� ------ _ Distance from nearest well__--_-_._--___._Distance from foundation--------------------Lining mafierial__.__--_-----_---_ ❑� -,_-,Size: Diameter-------------------------------- ------Depth ------------- ------------------ -------Liquid Capacity..... rrvy: Distance from nearest well------------------------------------ r -• ---------gals. - __-_- ._Distance from nearest building ❑ Distance to nearest±lot,1ine "4- --_:_ i 4 --------------.................. -------------------------------------------- -------- emodeling and/or repairing (describe):_.__- __-- /! # ----- tS ;I --------------------•--•----- -- ----------------------------------------------------- ---- -- ------ --- - ---------• ----- --------------•--- ------ ------ ---- --- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, d rules and reguiatio of the San Joaquin Local Health District. : I y , (Signed)-------•----------------- ------------------------------- - ----pl� ..._ --- ------------- - , ------- BY:----------------•-- ----------------- fit-. ---------- ----------------- Wells act ner an �o Contractor) (Plot plan, showing size of lot, location of system in relation fi?I wells, buildings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY tl APPLICATION ACCEPTED BY---------------- I-------------- ---------- r REVIEWED BY__.. , DATE °------------- -��,� - ot ---------- ------- DATE BUILDING PERMIT ISSUED----------------------------------------------------------- ---------------------------------- ------ Alterations and/or recommendafions:----------------------___ - DATE---- ------------- ---------------------------------•---------•--------- ----- ---- ------------------ •---- FINAL INSPECTION BY:-.----.-_--- _�: •'• � ----------- --------------------- Date----- E/ ):7-- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 30 130 South American S+ree+ 1 0 West Oak Street 132 Sycamore 5#Pse# 814 North "C" 5#Pee# S+ockfon, California Lodi, California Man+eca, California Tracy. California ES-9-2M Revised W-2100