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;r I\1 APPLICATION FOR SANITATION PERMIT Permit No. ............�.._ __ . (Complete in Duplicate) -- — l;ate fss6ed __- -��___�� Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the wort; herein described. This application is made in compliance with County`Ordinance No. 549. j JOBADDRESS AND LOCATION-•-•----------- 5------------- l L't----------------------------------------------------------------------------------------_------------ Owner's Name-----------------------------------------------Gcw------------ ba- -- --------------- - - ------------------------------------ Phone---------------------------- -------- Address.-....----------------------------------------------------- -------Address.----•----------------------------------------------•------------------------------------------------------.....----------------------------------------------------------------------•----------------------- Contractor's Name : ----------- Q 5 _ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ s Number of living units: -------- Number of bedrooms __-3__ Number of baths _1_____ Lot size ------ ____-------X___�Sf�------------------ Water Supply: Public system ❑ -Community system ❑ "PrivateA Depth to Water Table 0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoX New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank_or cesspool permitted if public sewer is available within 200 feet.)r Septic Tank: Distance from nearest well___-e t____Distance from foundation-----1Q________.Materiai______---- f -_-.-.-. _ --____. No. of compartments-. �------r pcity- . Disposal Field: Distance from nearest well-_40--l-Distance from foundation-----14----------Distance to nearest lot line_____'f___ .Number of lines_____________-I jLen th of each line__W0__rf0_,30___-Width of trench.________I'll------------------ i Type of filter material--------- -___-_------Depth of filter material------/_5 ......... length-----------_.-_-______-__._..-.____ Seepage Pit: Distance to nearest well-------------------�__-Distance from foundation--------------------Distance to nearest lot line--_-_---__--___._ r ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------------.---------Depth----------_-_--------------_----. ' Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___.____________._.__.______________ ❑ Size: Diameter--------------------------------------Depth_--------------------------------------------------Liquid Capacity- --------------------------gals. Privy:: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------.__________- j ❑ Distance to nearest lot line--------------------------------------------------------------------•----•---------------------I------------------------------------------- j i Remodelingand/or repairing (describe):-------------------------=------------------•--•--------------••----------------------------------------------------------------- --- --------------------------------------------------------------------------------------------------------------'--------------------------------------------------------------------------------------------------- ------------ --------------------------------------------------------------------...-----------`-------------------------------------------------------------•-••-•-•---------------'-------------------------------------'•------------------ i I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, 5 e laws,'and rules an ulations of the San Joaquin Local Health District. (Signed) ----- --�'�------- -- - i = - (Owner and/or Contractar)3. By:--------------------------------------------------•------------------------------------------------------......--•------------__(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 APPLICATION ACCEPTED BY--------------------------------- -------------_ - DATE �� = 1 REVIEWEDBY---------------------------------------------------- --------------------------------------------------•---------•------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------1--------------------- -------------------•--------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------------- ----------------------------------------___------------------------------------------------------------------------- - ------------- ------------------- ------------------------------- ----------:--------------------------------•-------•------------------------------------------------------------------------------------------- ---------- ----------------------I——-------------------------------------------------------I-------------------------------------------------------• ---------------------------------------------------------------------- -------------------------- --------•----------------------------------------------- �A�4�*-- �`''— Jr� y FINALINSPECTION BY-------------- ------------------------------------------------ Date------ ------------------------------------ ------------------------------------ i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California I; . Revieari W-7100