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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issueui1=^``, S___y Application is hereby made to the San Joaquin Local Health District for a permit to construct and install+he work herein described. This application is made in compliarice with County Ordinance No. 549. JOB ADDRESS AND LO� TION_�-u----- ! - Owner's Name------------------- `'f `t '« `•+! - Phone----------------------------•------ Addressi _ -------------------------------------------------------------- Contracfor's Name-..:: . ,' .�1� `----- ' ' ' �'-� rT��w�� Phone r,7�1� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ X Number of living units:-___j-___1 •umber-of.bedroams . - Number of baths �_____ Lot size _____ _ __ f- ----�--------------- r � Y Communitylsystem -E] Private E] Depth to Water Table ______-. ft. Water Supply: Public:system Character of soil to a ldepth-6f 3'.feet: Sand ❑,., avel ❑ Sandy Loam ❑ 3y Loam ❑ Clay [] Adobeardpan ❑ Previous Application Made: Yes V"�<o4jK\j(,(New Construction: Yes �J/No E]TYPE OF INSTALLATION AND SPECIFICATINS: (No septic tank or cesspool permitted if Fpublic se 8 is available within 200 feet.) �7,,stance from foundation-_A5 -� Septic T Distance from nearest`wel ___ �_! --______.Material_________ ______�______ _ __�____.. ---- ._ Size � �' ---Liquid depth Capacity � -[fi-- ❑al F' Dptance from rnearest well�� Dis Y---�-- ----�--- -- q p �..------ p Y---«4---- . .� n h__ r r � * , ------ Disposal .__P___�, •' ance,from,foundafion_ nearest lot•line_-%__________ i Dis Number of lines----_ -_-' -- n-------Lerch of each lune-----C -- - ��------Widthcofttre c � c - Type of filter material� ____Depth,.of..filter maferial___- _____Total length---- _-----------______________________ Seepage Pit: Distance to nearest,well----- '' ______Distance from foundation------------------..Distance to nearest lot line____.--_.-_-_____ . ❑ Number of pins--------------'-- _--'Lining material----------------------.Size: Diameter------------------------Dept h---------------------------------� Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- material____________-__-_-_________--__.-_-_ Size: Diameter-----------:v I-----------------------Depth-- �T--------. --------- -- Liquid Capacity--------------:------ -gals. �. Distance from nearest buildin Privy: Distance fromeearest well------------------------------------------------ g' ---------- ------- -- --- ------- g ❑ Distance to nearest lot�line.._-------------------------------------------� ---- -----------•------------------------------•--•-••----• iY T i---------------------------------------- ----------------------- --------- ----------------- ------------------------------------------------ ----------------------------- �' 1 ------ ---------------------- _-• 1 hereby certify that 1 have prepared this application and that the work will be donut in accordance with San Joaquin County ordinances, State laws, and rules: an regul�on`s of the San Joaquin Local Health District. 4`(Signed} 6 -- f !� ---f .c1C ran /or.Contractor] ( --- --------------- Title ! - t_.�_e_,4_ BY� ---------- _J----- �---------- f J ;- 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------- DATE REVIEWED BY-------------'. ---------- ------------------------------------ DATE-- �� 3_ --- ---------------- BUILDINGPERMIT ISSUED__..---•------------------------------------- - ----------------------------------------------------- DATE = - Alterationsand/or recommendations------- ------------------------- ----------------------------------------------------------------------•-----------------------------------------•------------ -------------------------------------- -----------------------------------------------------------------------------•-------------------------------------------------•--------•-------------------------------------------- ----------------------- - ----------------------------.----------------------------------------------------------------------------------------------------------------------•--•--•- + -----------------------------•----•- -------- --------- ------ - ----------=•-------------------------------------------------------------------------------- FINALINSPECTION BY--- ---------- --------- ------ Date------------- ------- -------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street l StoAfon, California ° Lodi, California Manteca, California Tracy, California t E5-9---2M 8-51 Revised W-2100