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APPLICATION FOR SANITATION PERMIT Permit No Z -_�_�"1_/_______ (Complete in Duplicate) / Date Issued/ �_ _ '___1 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. JOB ADDRESS AND LOCATION____/_ ' ------ Owner's Name--------- -------r------ ------------ ---------------------------------------------- Phone----------------------------------- ��gg 4 Address..-- -/-!_ _ - .._..... ---------•---•----------------------- ----------- --------------- Ono Contractor's Name--------- ------- -------------------------------------------------------- Phone_.7-- ---- ---------------- Installation - -�-. Installation will serve: Residence KI Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms __..Number of baths --I--- Lot-size __�__ _ _________________________ r Wafer Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe Hardpan E] Previous Application Made: Yes Ej 1. N,X',,, New Construction: Yes ❑ No J 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----------------------- \ { Dd: Distance from nearest well_-Aqpw- ---,._.Distance from foundation------/C-1 Distance fo nearest lot line_____ Number of lines_____________ ___ _ a __ Length of each line_________ Width of french____. _ *_________________ Type of filter material___ _; ___.' Depth of filter material______-_. _____Total length___________li: --______________________ �f+ Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________Distance to nearesf lot line-___--___________ ❑ Number of pits__'_________________Lining material-----------------------Size: Diameter----------------------- 1 Depth-------------------------------- Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining material------_------------------------------- { F-1Size: Diameter---€----- ---------------------------Depth----------------------------------------------'---Liquid Capacity----------------------------galls. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building________________________________-_-___--. ❑ Distance to nearest lot Iine----------------------------------------------- ---------------------------------------------------------------------------------------------- j 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, State laws, and rules and regulations of the San Joaquin Local'Health District. - ---. _ (Signed., � .: ii� �or Contractor) --------------------------- Ti+le__-- � E By:-- ------------- ---------------------------------------------- -I ) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 6e placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- DATE REVIEWED BY------------------------------------- _ DATE:- ------------- BUILDING PERMIT ISSUED--------------- - DATE---------------------------------------------- Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------•------------------ ---------------------------------------------------=-•----------------------- --•---------------------------------------------•------•----•--"--------------------------------------------•------------------------•---------- - - ---------------------- ------------------------------------------------------------------------------•-------------------------- FINAL INSPECTION BY: - --- -- - --- -- ----- Date-----./-- ----------------------------------- - i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Si California Lodi, California Manteca, California Tracy, California I ES-9-2M 8-51 Revised W-2100