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5 p 1y°I� 'APPLICATION FOR SANITATION PrKM1T Permit No. ....--.--L..�'t..�...... (Complete in Duplicate) / Date Issued ..../�:.F�y 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 lY^^ n JOB ADDRESS AND CATION- z W _ ---.. .. - ...--- - --------------------- ...................... Owner's Name..... - ... ....ter. ....." .------ ....-- a •... ........................I-------------------------------- Phone..-;F/ Contractor's Name.......--'--- '--'- -- - - - -------- ------ .:.--.............-'- ............... ..............' Phone... Installation will serve: Residence Apartment H se [M] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .--/.- Number of bedrooms -.r2 Number of baths /_. Lot size -. -----< -------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water TablgQ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adol;n Hardpan ❑ Previous Application Made: Yes ❑ Nox New Construction: YeA No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: Distance from nearest well.................Distance from foundation....................Material---------------------------...................... No. of compartments------------------------Size------- .Liquid depth--------------------------Capacity....................... Dispos I Fi d: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line................. 4 Number of lines-------------•------------------Length of each line.--.-' '----------------Width of trench.--------------------------------- Type of filter material-------------------------Depth of filter material-------..............Total length......................................... i t Seepa a Pit: Distance to nearest well. ..-.......Distance f m,fo dation./�..........Distance #o nearest to --- r t Number of its.... _-----------. Linin material ..Size: Diameter......•..._.....Depth_... Cesspool: Distance from nearest well.................Distance from foundation------------.......Lining material-.. --------------------------------- El Size: Diameter-----------------------------.--------Dept h---------------------------------- ----------------Liquid Capacity..---------------------.-.gals. Privy: Distance from nearest well_...................._.------...__-----._..Distance from nearest building.......................................... ❑ Distance to nearest lot line........_..........'---------------------- . ............................--"-----------------------------------------`-----' - 0 Remodeling a repairing (describe):---- .lnr -.... Q� r✓ .C� .L..--. a�,•� . ...---'---- .. -----------•................ .----------"-'----'------ -' .......................-..........................------------------'----11----------- _------ --------- ----------------------------------- ---------------------------- .. d I herebyy certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sf fe laws, and rules and gulations of the San Joaquin Local Health District. (Signed).... � f` ........................... ---------------------- - ' - (Owner and o onfractor) .. $ - - J - - (Plot plan. showin size of lot, location of system in relation to wolfs, buildings, eta, can beep) on reverse ide) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- DATE.�x ................. REVIEWED BY -- ..... ----- - - ...__...._...................... - -- - .-..... DATE- ¢ ....- BUILDINGPERMIT ISSUED............ ...................."--'--'-- -'---------------------•------- ----••----- DATE......................-.................................... Alterations and/or recommendations:................................................. ----------- ............. ................... I..................................... ........................................ ----------------------- .... ------......------=-......•.----. _.._ .............................................................................----------- FINAL INSPECTION BY:-. -5................... ........... Date.. ...— ..4..- kf................................ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak S!raef 132 Sycamore Sfreef n 814 North "C" Sfreaf Sfockfon, California Lodi, California Manfeca, California Tracy, California A ES-9-2M Revised W-1100