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APPLICATION FOR SANITATION PERMIT Permit No. __ - - (Complete in Duplicate) Date Issued _� (_10_- pplication 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-_____,- _ ---•-•__� , t Owner's Name -- . ------ --- -=---- - -- ------- --- ----- 1 ---- Phone -- -- - ---- ---------- I Address - Contractor's Name - - �'� `'� Phone Z-0--- ------ - - -- - - - --------- Installationwill serve: Residence Apartment House ❑ Commercial ❑ Trailer Courf ❑ Motel ❑ Other ❑ Number of living units-./--- Number of bedrooms -_/- Number of baths -/__ Lot size __ ---- Water Supply: Public system Community system ❑ Private ❑ Depth tc'Water Table"ft. Character of soil to a depth of 3 feet: Sand ravel Sand Loam Cla Loam Cla ❑ Y y ❑ y ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ } ' TYPE OF INSTALLATION AND SPECIFICATIONS: 0o septic tank'or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearest weil� pistance from foundation/_ ____�__-Mate i I___ Elio No{ of compartments__- _--___ ize-- . Liquid depth 'y Capacity--- d-� - Disposal Field: Distance from nearest well/l/lA_ .__-_.Distance.from foundation__9_a___ _-__Distance to nearest lot line__f�--- [}� Number of lines-_4. ____,___-- Len th of each lirie__ _��__ `_ 9 I - �„ j--W— idth of trench_____ Type of filter material'Sv - - •--- of filter materia__ __ �- - ,.. _,. h ._ ---------Total length-------l ------------------ n Seepage Pit: Distance to nearest well------------'_-------Distance from fo'undation-------------- ____.Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------4-----Size: Diameter_-----------------------Depth--------------------------_ Cesspool: Distance from nearest well-----------E-----Distance from foundation-------------- material__________________ Size: Diameter --------Depth ----=---------------------------'---Liquid Capacity-------------------- ----- gals. In. Privy: Distance from'nearest well-----------------,C3_------------------------- --_-_Distance' from nearest building____---_____-________ ❑ Distance to nearest lot line----------- ___ ___ _______ I - --------------- ------------------------- Remodeling and/or repairing (describe] - ----------- -----Al� . --- ------�' ------------- - ' . ------------ --------------•------------------•----•------ •------------- -------------•----- ---- ----•----- -------------------------•------------------------- - -------------------------------------------------------------------••- ------------- ------- ------------------------------------------------------I----------------------------------------------------------------------- I------------------------- • - ------ ------ ----- ------ ----- -- ------- -- ------------ ---- ----- ------ - --- ----- = 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) ' --- - t BY� ' - ---_--- _ - :(Ti+le) :-[O(owner and/or Contractor) -- --------------------- ot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------------------= - DATE REVIEWED BY-------------------------------------- ----- --------------- -- -------- ------- --------------- ---------------- - DATE-----. _- --------� UILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------: ------- DATE------------------- Alterations and/or recommendations:_________ - --------------------------------- --------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------- ----------------------------------•-------------------------------------------------- ------------------------------------------------------------------------- -------•-------------------------------- ------------------------------------- -------------- ------------------------------------------------------------------ FINAL INSPECTION BY:--------- -r---- � �� Date ?// ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" Streat Sfocktort, California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100