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APPLICATION FOR SANITATION PERMIT Permit No. __I�.-�•G- -� fr (Complete ir�Duplicate) _Date issued ___-- _-3 _9. ork herein described. Application is hereby made to the San Joaquin uin Local Health District fora permit to construct and install the w This applicaiion'is made in compliance with County Ordinance No. 549. I JOB ADDRESS A LOCATION----- - ---- ---- --- --- ----,�- --- - ------ Phone------------------------------•---- -- Owner s Name- - --------- ----'--------• -----•----- ------------ -------- -------- -------- -------�- ----------------------------------- --------------------------------- Address-------------------------------- --- ----------- ------------------------------------------------------------ --------------------- ------ ------------ Phone----------------------------------- ,. Contractor's Name-------------------------------------------------- Motel Ott ❑ Commercial . Trailer Court ❑ ❑ L Installation will serve: Residence [�partment House ❑ ❑ �`�� I�L Number of living units: _/---- Number of bedrooms _) ----- Number of baths Lot size --- --- - --- Water Supply: Public systemCommunity system 11Private ❑ Depth to Water Table -------- ft. Gravel Sand Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hard pa Character of soli to a depth of 3 feet: Sand ❑ ❑ Y Previous Application Made: Yes ❑ No � New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND l perms ted if � [No septic tank or'cesspool permitted if public sewer is available within 200 feet. -0----------.Mate(--- Septic Tank: Distance from nearest we*------------Distance from foundation_-� Capacity---S-1116.-- ! No. of compartments------ ------Size----� �---3-Liquid depth-------9- ------------ e Distance to nearest lot line--4-- ------- Distance from foundation_ _,a-__-_--_. I Disposal Field: Distance from nearest wellnth of each line_ _ -- Width of trench---,2----------------------- Number of lines_---:-__- __-_ g y�-- 1 Total len9+hGH Type of Uter material__-�= -- -- epth of filter material-- ---------- -- � _ Seepage Pit: Distance to nearest well_---_________________Distance from foundation-_-_---- __ Distance to nearestylot line-__------------ Linin material = _ ` Size: Diameter �`Y- Depth- ------ -------------------- ❑ Number of pits ------------------ g T "t ,\ i Cesspool: Distance from nearest well----------------- from ffouunndation.--.-_f---- Lining material_---_ _.--_---._--- r---- -Li Liquid Capacity gals. ❑ Size: Diameter#-----------------------,-------------Depth--------------------- ----- - --- q P Y Privy: Distance from nearest well---_----------------------------------------------------------------------Distance}from nearest building------------------------------------------ --------------- ❑ Distance to nearest lot line---------------------- -- - - ------- • Q - -------------------------- -. t Remodeling and/or repairing describe]:-_--i-f1=�- -----_-_-__--- ------------------------ ----------------------------------------------------------T--------.-_____-_-_-__- ` ------------- -------------------------------------------------------------------------------------------------------------------------------------------------_--_-_----__-_----_-------__------__------_------. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun j ordinances, State1law an s and regulations of the San Joaquin Local Health District. - / t _-__-(Owner and/or Contractor( r ........................... ----- -------- -------- ------ ---------- -------------------------------- (Signed •----•-- 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 ------------ _ DATE --=- --------- -- ----------- ------- ---- APPLICATION ACCEPTED BY------------- -------- -- -- ---- F DATE- -y r --- --- ------- -- - - - REVIEWED BY----------------------- ----------•� - DATE- PERMIT ISSUED-------------------------------- ----- Alterations and/or recommendations:--.-----__---- ----------- ---------- k ---------------------------- - ----------------- - - -------------------------------- ------------------------- -- ----------------- -----•------------ i --------------------------------------- � Date--FINAL INSPECTION BY:.__---�'-_-_--- --r-_--g ----- ------------•----- ------------------------------- SAN JO QUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Tracy, California Stockton, California Lodi, California Manteca, California Y� ES-9-2M , Revisea 1.57 F.P,CO-