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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) g • Date Issued L! Aplica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, s application is made in compliance with County Ordinance 549. f � r � r JOB ADDRESS AND L TION---___""" -_ "_- ---_- - - -- ----------------------------------------------------------- Nam -------- ---------• k Owner's Name ----------- l��- -- Address_. . . . ------ = Phone - ---• = Contractor's Name--------_.----_ f ` "' ---• --- ----- �-`�- --------------- -----------------------------------------------'�-----• ------•-•--- Phone------Z-/2�9`, Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer„_Court ❑ Motel ❑ Other ❑ Number of living units_,,---- Number of bedrooms—Number of baths --- Lot size ---- " pP--------------------------- Wafer "•"""-_- ------Water Supply: 'Public systemCo,mmunity system E] Private E] Depth to Water,Table�:�Ft. Character of soil to a dept o}f f 3 feet-- Sand ❑ Gravel ❑ Sand Loam Clay Loam k � Y ❑ y F ❑ Clay ❑ Adobe' Hardpan ❑ Previous Application Made: -Yes ❑ No D�,_ New Construction: Yes ` No ❑ :. a TYPE OF INSTALLATION ANb SPECIFICATIONS: + i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p ' Nis Distance from nearest we ,. cam •Distancefrom foundation-----•----Materi I___"�r__�--0 r { Septic Dist of compartments. ._" --____-"""...._Size" z__" """__ / 1. "--Liquid depth-Jr--}� - .-_--Capacify.---- �C� Dos ( Field: Distance from nearest ws!#trz//`."-_Distance from foundation--"� Distance to nearest lot ine.--"�------- Number of lines----"---p"----__ Length of each line---"-" f �j 9 �� i .".Width of trench ---------------- Type or filter materials �" -s� , ---_Depth of filter material""". - Total length -----------------Pit: Distance to nearest Distance f m, foation" .'_'� lin " Distance to nearest lot e"- Number of pits.-_."�------------_-Linin material. Lining /..Size: diameter"""-- ----- p ... De th � 2' ------ C - --Cesspool: Distance from nearest well----------------"Distance from foundation---------1.,--------Lining material--___----_-------------.- . ❑ Size: Diameter.-- -- -------- Depth----"" Li uid – = = Capacity _ Privy: Distance from nearest well-------------------- Distance from nearest building ❑ 'Distance to nearest lot line---------------------_--- Remodeling and/or repairing I -•------•----------------------•--------------------------•----------------------------- -------------------------------------------•----------•=---•----=•-----------------------------•----------•-•----"---------•-•------------------ -------"-----------------•-----------•-------------------------- -------------------------------------------------------`----•----------------•-----•------•----------------•-----------------------------•------------------------------------------•----•-------------------•---- I hereby certify that.1 have1prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St ws, a rules and'regulations of the San Joaquin Local Health District. (Signed)..----- --- �J ------------ ,---------------------------------------------------------------------------------------------- Owner and/or Contractor BY: =•----Z--'...------`-••------------------------- -- ------(Title-- ' -- - - -------------------------------- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings. etc., can be I ed on r erse srdeJ. g P FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------- DATE- _ - ----------------- - - ----•----------• ------------ ---- REVIEWED BY--------------- ------------ DATE--- BUILDING PERMIT ISSUED •------------- -- ----------------•--------------- DATE------ VS Alterations and/or re mmendations:-_." ---•---•---------------------------- ----" ---------------""-""" ----------------- -------- ---------------- X45 ------- FINAL INSPECTION $Y-=--- --- - ------ - ------------- Date------ ------ _�F7/ ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockfen, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100