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APPLICATION FOR SANITATION PERMIT Permit No. ...tle ............ (Complete in Duplicate) Date Issued - / 5 -- ,,�✓ 14-0 rn install the work herein described. Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and This application is made in compliance wi h County Ord'n rete No. 549. 0-2F3 JOB ADDRESS A OCATI N -�_•---- r erPhone------------------------------------ Owner s Name------- _----- -=- - -----'----- -- - ---•---•-•--•-•...---•-•-•••---•••---•••••-- •----•-•••------•-•--•---•••-•......--•---... Address-------`�--�--�-- ----------•---•--------•--------------------------------------------------------------- ' Contractor's Name--- ______ Phone-------------------------------- ------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ -'l1- ------------------------- Number of living units: __: -_ umber of bedrooms _--Z. Number of baths .r"' Lot size -55 Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel [I Sandy Loam Clay Loam ElClay F] Adobe Hardpan C]Previous Application Made: Yes El No New Construction: Yes No ❑ 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_________________Distance from foundation--------------------Material_-_--__.____-___-_--_-__--_------_._-_-----._.._. ❑ No. of compartments--------------------------Size-------------------------------Liquid depth-------------------------Capacity----------------------- Disposal Field: Distance from nearest well------s----------Distance from foundation--------------------Distance to nearest lot line----------------- f-1 Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of fit material-------------------------Depth of filter material-----------------------Total length..........__�............................. ce from foundation to nearest lot line----------------- Seepage Pit: Distance to Nearest well______________________Distan ❑ Lining terial-----------------------Size: Diameter------- --------Dept ----- ------------------- Number of fits__________________ _ Cesspool: Distance from ne est w IlIA:� istance from fou clition---�Q--------- m"mg material-- ---------- ---- -------- I � �J - dSize: Diameter-- .x. Depth -- V----------------------------Liquid CapacityC / gals. �y� _ Distance from nearest building--:S31------------------------------- privy; Distance from nearest welL_._.l_W ____ Disfance fo nearest lot line----- -- --. ..........................•---•. -•-•-•--------•----------------•--•-------•---------- --------- Remodeling and/or repairing (describe)______________________________ ---------------•------------------------------------------------------•---------------------•------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, StateAws,'anO rules and r ations of the,,San Joaquin Local Health District. (Signed). ... --- ..... . •. -- ------(Owner and/or Contractor) Title BY:----------------------------------------------- ---------------------------------------------------------------------------------( ) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - ------------------------------------<----------- - --------••---• DATE�------------------------------------------------- REVIEWED BY-------------------------------- --- DATE--�-----------•-------------•-------------------- - .. DATE....... _. -----------------•---------- BUILDINGPERMIT ISSUED...............................--------------------------------------------------------- �T Alterationsand/or recommendations---------------------------•--------------------.................•........................................................................................ -------------------------------------------------------------------------------------- - - ------------------------------------------------------------------------ --- 1.5� ----------------------------------------- FINAL INSPECTION BY----------------ztL---------•---------------- Date- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Manteca, California Tracy, California Stockton, California Lodi, California ES-9-2M Revised W-2100