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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued _______________________ 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. 549, _ _ --------------------•------------- - .P tet-.+r.�' JOB ADDRESS AND LOCATION----- -------- � - - ----------------- ------------- -- - •� �r ------------- Phone------------------------------------ Owner's ------------------------------- r � - -------------- ------- Owner s Name__________ Address-------fes y ��-_ — -T? - ------------------------------------------------------- Contractors Name----- ------------------------------------------------------ Phone------------- >° Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ I ___ Number of bedrooms ___+� Number of baths ___�__ Lot size __ fir-----`-'"=- Water Supply: Public system ❑ Community system '❑ Private Depth to Water Table ?D-- ft. Character of soil to.a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ " New Construction: YesOr 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_ 5n______Distance from yfoundation___ Materiai_--_C-_e------------------ __4 - - -- -------------- Capacity--- No. a atit Y No. of comartments---------- Liquid depth-- IN � ' �---- _J ` , �U-_-_-Distance to nearest lot line___ ___________ Disposal Field: Distance from nearest we!I_. _.-Distance from foundation_-___/0-_-Distance ❑ Number of lines_____6�P-___ Length of each line_____(0� {_ Width of trench___________________________ Type of filter materiai�__� -- Depth of filter material-----1_--iir..........Total length----3-�z0-------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- ❑ -Linin - Depth--------------------------------- Number of pits--------------------- g material___--_---------- ----Size: Diameter----------.-------- - g material-------------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation___--.__----_______.Liningals. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------g P.nvy: Distance from nearest we11_______________________________---.___-_____.___Distancs from nearest building------------------------------------------ ❑ Distance to nearest lot line---------------------- -------------------------------------- Remodeling and/or repairing (describe):-------------------- ------------------------------------------------------------ ---------------------------------- ----------------------------------------------------------------------------------------------------------------- ------------------ ------------------------------- -- ----- -- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, 51ate laws, and rules and regulations of the San Joaquin Local Health District. --------- ----------___.---_(Owner and/or Contractor) (Signe .. ..�.— BY:-------------------------- -- - - ------ Title (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 = . REVIEWEDBY---------------------------------------- y� ----- �- -- -a ---------------------------------- DATE_-------------------------- ------��- --------- BUILDINGPERMIT ISSUED------------------- ----- --------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations----------------------------- ----------- -----------•------------ ---------------------- ----------------------------------------------------------------- --------------------------------------------------------------------------------------------------- FINAL INSPECTION BY,- � = ----- Date �`� 3 M_9 cl SAN JOAQUIN LOCAL HEALTH DISTRICT Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street 132 S Y ick#on, California Lodi, California Manteca, California Tracy. California ES--9-2M 8-51 Revised W-2100 ��