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APPLICATION FOR SANITATION PERMIT Permit No. ; (Cpete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No.'549. F JOB ADDRESS AND LOCATION-_7 "' , ------ ---------- Owner's ------' - - ---------------------------------------------------------------- k ! l�Ls Owners Name-------•-----------------------•---;---- '- -�.;------ �- ------• ----------------------------------------------------------------- Phone------------------------------------ Address---------------- --- -- -- - Address---------------- -•-----------------------------'i Contractor's Name--------------------#� f Phone -------------- ----------- -------------------------------=--------------- Installation will serve: g Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms , -___ Number of baths -_1V-_ Lot size --------M: s---______-.--------- s 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 ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes.❑ -No'❑ New Construction: Yes❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: . s. " , (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----------------- from foundation- -________--Material------------------------------------------------- ❑ No. of compartments Size Liquid!depth-------s------------------Capacity----------------------- Disposal Field: Distance from nearest well-------_----------Distance from foundation------- ,---.-_-__..Distance to•nearest lot line----------.__--_-- ❑ Number o€ lines-----------------------------------Length of each line------------------------------Width of french.------------------------------- T e or filter material-------------------------De th of filter material---.----------.--------Total length------------------.----------------------- Seepage Pit: Distance to nearest well______________ _____ � ! , .____ _____________Distance to nearest lot line_..._.--_- t" __________ ag p_Distance from foundation _ + ❑ Number of pits--- -------- ------Lining material--------------- Size: Diameter----------------------.Depth------------------------------- - Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-____----_---_____.___._-.--__.-_ ❑ Size: Diameter- { -------------------Depth--------------------------------- ------------------Liquid Capacity-----,--------- -------------gals. Privy: Distance from nearest well---------------------} ---------------Distance from nearest building_,,----------.7 -------------- ------ yptt Distance to nearest lot line----------------------------4A-------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------- = ----- ------ ------------------- Qrlc of------ "'-----9--=----------------------- --------------•----------------------------------------------------- ----------------- -•-------------------------------------------------------------------------------------=--------------------------------------------- t I ------------------- ----------------------------------------------=---------------------------------------------------------------------------------------------------r------------------------------------------ ------- I hereby certify that'l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulati s of the San Joaquin Local Health District. .� ' --------------------- -----� ! [Signed)... -- ---------------------------------------------------------(Owner and/or Contractor) R By:----------------------- _ " --------------- Title --------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------ DATE.----------------- 2------------ REVIEWED ----------- REVIWED BY �/5-------------------•-------------------------------------- DATE---•--------- ` -------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------- ---------------------:_==- DATE--------------- ---------- --------•---------- Alterations and/or recommendations: ----- ----------------------- - �- --------------- ------------------- --------- --- ----- -- -- ---_----------------- ----- -- F ---- --- �i --- ---- ---- --------t-------------------------- ----- :---i--X--------4-- ----------- -------------------------- ------------------------------------------------------- FINAL INSPECTION BY:--- ---------------------------------•----- Date-------� ----- -_ -----_ (4 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+an, California ti Lodi, California Manteca, California Tracy, California t E5-9-2M 10-52 Revised W-2100