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APPLICATION FOR SANITATION PERMIT Permit No. __.�_G... .. (Complete in Duplicate) Date Issued _____/_L_P�S {; 253-2 D—nS Application is hereby made to the San Joaquin Local Health District for a permit o construct and install the rk he' n This application is made in compliant with County Ordinance,No. 549. ter_ _ , ss0 s` ' JOB ADDRESS AND LOC. TIO _ __ - .�" ' Owner's Na hone.------- -- --- ------- -----------------•-•-- -- - -----=----- ------- --------------- -------- Address ' ----------- ------ ----------------------------------------------------------------------------.------------------- = Contractor's Name-__- ------------ ----- ---- ---------- --------------------------------------- -------- ------------------•-----------------••- Phone.._•----.._...-•-----=-----•------- Installation will serve: Residence douse ❑ Commercial ❑ Trail r Court ❑ Motel ❑ Other t g !!.___ Number of bedrooms��_: Number of aths /_� Lot size ___ -✓.-/ __._..+,_______r._ Number of living units: 1 � � r Water Supply: Public system .❑ Commuriity systemat� Depth to"Wate`r ft. Character of soil to a depth.of 3 feet: Sand ❑ Gr � el 5 ndy Loam [j Clay Lo ay ❑ Adobe Of Hardpan ❑ Previous Application Made: Yes ❑ No l� New Con ruction: Yes �No ❑ FHA/VA: Yes ❑ No F � TYPE OF INSTALLATION AND SPECIFICATIONS: ,.(No septic tank or'cesspool permitted..if ublic;se er_is available within 200 feet. �� - .,�. _ Septic ank:, Distance from nearest wel � Distan from;fou dtion�_�� Materi I_:__ _____________________ _.. K. / ----- - Liquid epth- Ca acit � No. of compartments-- -- ----=- n .* 3ze-----=--- ,�( -----•-• / � p Y------•--- �..-- Dispos Field: Distance from nearest well�;_o istanc Mo lc5dation_l__D Distance to nearest lot line_71 / Number..:,of lines---------- ------ ------------- Length of each line________-_.._____ _.1I-____.Width of trench-__-.____--W-7 Type of filter matey �#, '(` epth of filter material__... __________ Total length___.__________ Seepage Pit: Distance to nearest well _----_-_--Distance from foundation--__•_-_-_.-___-_:-.Distance to nearest ------- Number of pits---------------------1 Lining material-----------------------Size: Mameter------------------------Depth_.._-------_--------------------• i Cesspool: Distance from nearest well _______________Distance from foundation_____________..__.. Lining material---------------------------.__._____. , ❑ Size: Diamester-".-.-�-�=f---i'-"�.�#-'-,----------Depth----------------------------------------------------Liquid CapacitY---------------------------- gals. Privy "=Distance from nearest well------/-_-- ---------------------Distance from'nearesf building---_---__---_____-------------------- I i 1 • ❑ Distance to nearest lot'Iine_r_--- --- ate, ' ',�-�. a.-c.• 3- 24' -r„.. . Re oriel' g a or repairi s be�:_-.--__------------------ -------- ------ - ---------------------------------------------;--------------------------------------•--------•--------------------------------------------- - �=----- - ---�---- -- k----=-------- - - -----------1--•------------• -- ---•------------------------------------ - ---------------y------ - !----------- ------ --------- - -�t�,----------------- -- I hereby certify that I have �repared this.application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules d regulations oft San Joaquin Local Health District. (Signed) - ------- ------ -------- 6---- --- - - = ----------- and/or Contractor) By:._. � _: Vz.�o-----------------•----------=-------- Tifle)------------------------------------ --------------------------- Plot Ian, showingsize of location of system in relation to wells,`buildings, etc., can be placed'-on`reverse-sid'e): ( P i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ _-----_ DATE� ------•------------------------------------------ i REVIEWEDBY--------•--------------------- �.-..------------------------------------------------- :----------------------- DATE BUILDING PERMIT ISSUED----------------------------------------•-----------------------------------------------•------------ DATE-----7fA---------------------------------------------- - Alterations and/or recommendations--------------- --------------------------------------•-------------------------------- --= -----------------------------=------- __....----------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 3 -------------------" -----------------------._...---------------- ---- -------- ------------------.------ -----------•--------------------•-• -------------------------------------------------------------------- hh �� 5- 11 FINAL INSPECTION BY ---------------, • Date------ -----------�---- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California ES-9-2M Reviseq 1-57 F.P.CO.