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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) .III ��/1-___ Date Issued ---- ,, -- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the pw ork.herein des, -'beds This application is made in compliance with County Ordinance No. 549. E JOB ADDRESS AND LOCATION---- _,�.„_______________� i__ ij �ry, AqOwner's Name------ ----_•--- _ Phonyf----------------- 40/ --------------------------------------------------------------------------- � ��. Contractor's Name__. ' �! --__,--___-____ -----•------------------------------------------- ----------- Phone---- ------------- --------- I - - --------- Installation will serve: Residence fFi Apartment House ❑ Commercial ❑ Trailer Court10 Motel ❑il Otherg� - ' ❑ Number of living units: � Number of bedrooms _ �_ Number of baths _�_ Lot Water Supply: Public system ❑ Community system ❑ Private, ( Depth to Water Table _' ft" Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam jCI y❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No, New Construction: Yes, No ❑ Fi A/VA"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-1-0-------Distance from foundation---! _ y-No. of com artments__ �1 rte;' E' ------------------------------ IX f � p a�--- ---------'-- Size_�'1"��---------------Liquid depth------ ---- ----- �_Ca aci Disposal Field: Distance from nearest well_ rg-0_-______.Distance from foundation---/d----------Distance to n alr' tot Ime_m' . � -------------- Number of lines---a------------------------/ Length of each line----�-r_T5'4--_&5-'Width of,.trencl�' - -s---••,-r-►-------- Type of filter material-��i�(-Depth of filter material----/,P ----------Total `len th____(i_ glQ- !I; , r —�S�pagajPit: D1`tance to ne res well___.-- -- Disficn'cer �ound?Ai!an,__/&_�_•---• istance to atjest I t ' x ___ 1 ------- �� Number ofi,t�\, ning ma rias _ e: Divr a ,n-- Cesspool: p Cesspool: Distance from nearest well-----------------Distance from foundation-----------.--------Lining material__.. i ❑ Size: Diameter------------------------------ -----Depth---- -'--------------- - --- -- - -- -= '- Liquid Ca acit �� -------gals. Privy: Distance from nearest well___________ ____'_'-------------------------Distance from nearest building lI �V------------------•--------------- ❑ Distance to nearest lot line f f =i Remodeling and/or repairing (describe)______________________________________ II. ---------------------------- ---------- ------------------•-------- -- - -- r z II. --• -----------------I ----------------------------------------------•--------------•--------------------------------• ------- - --- ---------•------ --------------------------------------------------------t---------------------------------- I hereby certify that I have prered.,this,.epplication and that the work will be done in accordance with San Joaquin County f pa�.�. ordinances,Stele la'rs, and rules and`eguWtons of the San Joaquin Local Health District. (Si ned 9 ) - -P�'�''�.� --------(Owner and/or Contractor) By:-------------------------------- - --••-------------------------------- -------- --- ---- - -- - --------- ----------(Title)---------------------------- (Plot-plan, showing size.of lot, location of. system in-relation to wells, buildings,.etc., can be-placed•on_reverse��ide). .,�-- i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ _ ------ _ _- -_ - "I DATE_ p_-I '-1 �--------------------------- REVIEWEDBY --------------------------------- ---------------------- - - --------- DATE---------- �� BUILDING PERMIT ISSUED------------------------------------------- ------------------------------------- DATE.----------- 1I- A Alterations and/or recommendations:-_-___________________ ----------------- _4-------------------------------- -------- FINAL INSPECTION BY:. Date- � - ��--q l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Sfockton, California Lodi, California Manteca, California Tracy[ California ES-9-2M Revised 1.57 F.P•CO.