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APPLICATION FOR SANITATION PERMIT Permit No. .. (Complete in Duplicate) Date Issued .___--��,---.s t q7— OZ 0.•--/2�— Application 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 Ordinance No. 544 � - JOB ADDRESS AND LOCATIO ---- -------� -------- le---'------ 6f..c---�--= - '�---'�----�-----we` - -------- Phone------------------------------------ Owner's Name----------- i-.- -- I&--eQ' '.�' Address-----------•----------- ---------•---------• --•-•--•-----------------------------------•------ ---------------------- -----------------------------•----------------------- Contractor's Name---------------------------------------------------------------------------------------------------------------------------------------------- Phone-----------------•------•---------- Installation will serve: Residence [E' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: __/__ Number of bedrooms ___ Number of aths /____ Lot size ---�_---- .�,x"'/_-C,_________________________._._-.__-_ i Water Supply: Public systemmunity system ❑ Private Depth to-Water Table 7.,g ft. Character of soil to a depth?'feeto : Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam p Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [R"�'_New Construction: Yes V?"N`c, ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if.public sewer is available within 200 feet.) _ Septic Tank: Distance from nearest welL__S5Q___---- DIstant from foydation__��_________-M �erial__1 � �: ® No. of compartm . ---d6----:---Liquid depth___ _________________CapacitY--- —__/_ i Disposal Field: Distance from nearest well_.5ZF Distance from foundation__, ----------Pistance to nearest lot line--/.5_____- Number of lines_______-a._.._--- -- Length of each line__��?_ __� �-��.Width of trench...... ---__.__________ Type of filter material___,5� D?rDepth of filter material-----/i---`r--------Total length------,/,3_/----------------------- S from foundation to nearest lot line_______.____...__ Seepage Pit: Distance to nearest well-_____________________Distance [] Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------ __...__.____.___------ Cesspool: Distance from nearest well________________Distance from foundation------------------ Lining material--------------------.---------._..___. ❑ Size: Diameter-------------------------------------Depth------------------------------------- - -------------Liquid Capacity-----:----------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------_----------------------------------- ❑ Distance to nearest lot line--------------------------------------------- ------------------------------------ ---------------------------------------------------- -- - 3 Remodeling and/or repa+ring (describe)__________________________________________ _ ------------------------ --------------------------------__--------------------------_-----Y--------------------------------------------------------------------------------------.-------------._____.----------------------------------------------- --------------- ------------------------------------_----------------------------_____________________________________________________________________________________________________________________________________________________________ t 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 r s and egulations off fhe San Joaquin Local Health District. +,.+-------------------------------------------------------------------------{�Contractor) (Signed)_-. 6 -----------------------------------------------Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F PARTMENT US ONLY APPLICATION ACCEPTED BY DATE----- ,�s ..�-Z--- ------------ REVIEWEDBY--------------------------------------------- --------------------------- ------------------------------------------------ DATE--------------------------------------------------•-------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------- ---------------------------------- Alterationsand/or recommendations:---------s------------------------------ ------------------------- •---------------------------•-------------------------------------------------------- ---•-----------------------------------------------------------------------------------------------------------------------------------••------------------------•- --------------------------------------------------- 1 -------------------- -------------------------------- --------------------------------------------------------------------- ------------------------------------------------------------------------------- ------- --------------------------------------------- -------------- --------------------------------------------------------------------- . r C' FINAL INSPECTION BY:---------- ' - �--------------- Date _�! � - t t SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California 4 Lodi, California Manteca, California Tracy, California ES-4-2M 0-52 Revised W-2100