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g � APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued _Y_-_S�-" 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. J08 ADDRESS AND LOCATION.-� ______--t,d/ c- (,------Owner's Name- c ---------- j ---- ---------`--7---------------------------------------- _ -------------- / .. - r --------- ----------- ------ Phone ----------------- ------------------ ------------------------ -__ --------- ------------------------- Contractor's ------------- on roc ors Name •----___ -------------------------------------------- ---- ----------- Phone Installation will serve: Residence,K Apartment House ❑ Commercial ❑ Trailer Court [j Motel ❑ Other [] Number of living units: -------- Number of bedrooms J--- Number of bat Water Supply: Publics stem -/--- Lot size _______ SX Z(d Y ❑ Community hs _system '0 Privatej' Depth to Water Table ft. - Character of soil to a depth of 3 feet: Sand [] Gravel [j Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9 Hardpan Previous Application Made: Yes El No K New Construction: Yes El No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic flank or cesspool permitted if public sewer is available within 204 feet. Septic Tank: Distance from nearest well__S�Q--_--Distance from foundation___,(_ � �Ca �"� No. of compartments -.Material-------------------------------- p -- ------�'--------Size------`-'�-�-tO-''-C - ---Liquid depth---------- --- d e7 Disposal Field: Distance from nearest well---_.. 9--- r Capacity________-- Number of lines---------1_dl _ -_Distance from foundation__1_Q-------------Distance to nearest lot line______-1_�__�--_• Length of each line------ 5--1 -t------Width of trench------------_Zt� '! - Type of filter material___j._ _ Depth of filter material__ `-8" r Seepage Pit: Distance to nearest well------------ ---_Total --------------- QGy (Zp ____Distance from foundation__________ ___Disfance to nearest lot line______________--_ �n ❑ Number of pits--------- ------- ----Lining material----------------------- Size: Diameter - -----------------Depth----------------------- {'(� Cesspool: Distance from nearest well-----------------Distance from foundation_.-_.____-_-___-___.Lining material-__-____________________ `J ❑ Size: Diameter----------------------- O -- p � - Liquid Capacity gals: 1 Privy: Distance from nearest well- _______-__ ❑ Distance to nearest lot line_"_______________________ Distance from nearest building------------------------------------------ -------------------- -------------- --------- - _ emodeling and/or repairing (describe)__________________ ---- -- ---------------------------------- --------- ------ ---------------------- ----------•-------------- ------------------------------•------- --------------------------------------- ----------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ---------------- ordinances, Sfate laws, and rules and regulations of the San Joaquin Local Health District. r (Signed) �. _ •� ' / ------------------------------------------------------------------------------------------------- (Owner and/or Contractor) ` (Plot plan, showing size of lot, location of system in relation fo wells, buildings, etc., can---- ielePlace on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ___------------------ --------------•--------------------------------------------- EVIEWED BY--------------- DATE--------------__ --------------------------------- BUILDING PERMIT ISSUED_ DATE. ......................................................... -------•---------- -- . ---------------------------------------------------------------------------- Alterations and/or recommendations-------------------"__-- -- - ---- ----•/��} DATE------------------- ----�------------- -------------------------- - - ---IL ,�. ! ------ T y______________ _..____Y __ _ � 1 --- ----�r ---------- S ------------- T- - --"_y-_""__f - d y FINAL INSPECTION BY.-._------------- ----------------- ---------- ------ ---- l ----.. SAN JOAQUIN LOCAL HEALTH DISTRICTS ` 130 South American Street .i d 300 Wesf Oak Street 132 Sycamore Street S+ockfon, California Lodi, California 814 North "C" Street Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100