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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein This application is made in compliance with County Ordinance No. 549. described JOB ADDRESS AND LOCATION- -- ------- _G ,� 1 ` �� -�/ Owner s Name. r -------------- - d� - - ------- - —�•_._.-_ Phone "- ---------------- - "- - Address-- GZ ,'? { +--- =--�--------/P� 1- ----- �,I�------------------------------------------- Contractor's Name---- ---- _ .e__ - ---------------------- -------- Phone--- Installation will serve: Resident ❑ Apartment House ❑ Commercial ❑ Trailer Co Motel ❑ OtherG! Number of living units: _.U.. Number of bedrooms _6.. Number of baths' _.. Lo ��Q X // —----------- - ---------- -- Water Supply: Public system ❑ Community system ❑ Private, Depth to Water Table - ft. Character of soil to a depth of 3 feet: Sand N Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0( Hardpan ❑ Previous Application Made: Yes ❑ No x New Construction: Yesk No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 280 feet,) from nearest �' ��Septic Tank: DaeWell Distance fp9m foundatio - __ ".. Material------- ---_------------ -- No. onpartme s ". �---- - ----Size.3---KX. 5.. Lud depth ------- pact} --- -� fo- Disposal Field: Distance from nearest well - 6V-----Distance from foundation---_ _..-"Distance to nearest }ot line__..-. 4 Number of lines------------i.------- ----- ------Length of each line-------S_57_. 'It----------Width of trench.------ - -'r---_-- Type of filter material "� _Jc 't _-Depth of filter materialJ_ ______Total length----------! -VC_....._ Seepage Pit: Distance to nearest weft ---- _---"---------Distance from foundation-------------------Distance to nearest lot line-------..__----- - ❑ Number of pits----------------------Lining material-------------- -- ----- ..¢e: Diameter-------------- --- -._Depth --- -- - ---•------- Cesspool: Distance from nearest well__ ---------- _Distance from foundation. _ -------Lining material-----.------------------ _ C} ❑ Size: Diameter.____ ------- -- -.._Depth-------- --- --- ---- -- Liquid Capacity- --------- ---------- _ga14 Privy: Distance from nearest well-----_------------------------------- -----.-Distance from nearest budding ❑ Distance to nearest lot line----- "-------- -"- Remodeling and/or repairing (describe)---------- -- ---- --"------- --------- ------------------------ ---- ---- - - -- --- ----- ------ --- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stag laws, and rules and regulations of the San Joaquin Local Health District. (5i ned ? ? ` 9 ) ---- - -- - ---------- ------- -- - -(Owner and/or Contractor) 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- ----------- REVIEW "-------- -- - - ED BY----" - ------ ---- ------- - � - / BUILDING PERMIT ISSUED DATE (�. + ` 4 ----------------- ----------------------------------------- DATE.._- 0-. F Alterations and/or recommendations:............_.___ - -- ------ ----------1--------- --- ------- ----------------- ------------------------ - ----------I------------ ----------- -- --------------- - ---------- - -- -- -- --- - FINAL INSPECTION BY:. Date""------- ------ - y "- - - �- = SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California E5-9-2M l0-92 Revised W-2100