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APPLICATION FOR SANITATION PERMIT Permit No. _---- <br />{Complete in Duplicate) ,-." .• <br />Q. Date Issued la_`� ._y?- , <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br />This application is made in compliance with County Ordinance No. 549. e <br />JOS ADDRESS AND LOCATION .1-8 •—r-^��^ � <br />---_.----- .�?.--------------- 1_Q-�--------- ------- <br />Owner's Name Z`r U.t G•Phone <br />..... .-----•----•-••---------... Phone��"�FC1J C�•------ <br />Address------•-----------•----•.....--.................... G � �Q <br />Contractor's Name-----------------•----•-----------------._.C�.1���r......._.... J..�^ ...... Phone... -------------------------------- <br />Installation will serve: Residence Apartment House ❑ Commercial D Trailer Court ❑ Motel ❑ Other ❑ <br />Number of living units: _....... Number of bedrooms __3__ Number of baths --- Lot size ........�fo.a X------ ---- -d ---?-. <br />++�� , <br />- <br />Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table..(_ _ ft. <br />Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 'Hardpan ❑ <br />Previous Application Made: Yes ❑ No 54 New Construction: Yes ❑ No �( <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br />Se tic Ta pk f .M Cp7stance from nearest well .... ._:.------- Distance from foundation ........ .......... Material...................... <br />l No. of compartments -- -----------i ......size -----........._ -----------Liquid depth---- ------------- Capacity --- ----- ------------- <br />" r <br />Dissl Field: Distance from nearest well_._�!rn isistance from foundation ----- 1p _._.._.Distance to nearest lot line ------ .._. <br />Number of lines... -_---_-.-1___.. Length of each line ....... ___.3_'flp___._....Width of trench- _......-__.. <br />Type of filter material- _ ... epth of filter material ..... length ............... -.................. <br />3% _ 0' <br />r <br />Se a e Pit: Distance to nearest well ---------- ^^'....__Distance from foundation ----- ...Q... <br />. f <br />.___.Distance to nearest lot line..._ --- <br />_._ <br />Number of pits---/__ Lining material _.......... 3..�... Deer!'------- r <br />r <br />Size: Diameter.._.._....—�.......... ... <br />esspooI: Distance f:-om nearost well.................Distance from foundation -..._-_--_-____-___.Lining rnateripl...... <br />❑ Size: Diameter ----- ..------ .-------------------- . Depth........._.------° ................. .---- ...Liquid Capacity -- - ._.......-•----•-•--•-gals. <br />Privy: Distance from nearest well .......................Distance from nearest building ......................................... <br />❑ Distance to nearesl !at line .........---•-•-•---•• .................:: ............................ --------------------- - ... <br />Remodeling and/or repa;ring (describe):--._--._..............._.--._-_-.._-.-_-..._-_-_----...._. <br />--------------------------------------------------------------------------------------------------- - <br />............ --------- <br />---------------------- .--.--- --.•-- rn <br />........... ........------------------------------- <br />--------------------------------------------------------- <br />- .. <br />----------------------------------------------------------------- <br />I hereby certify that I have prepared this application and that th-e work will be done in accordance with San Joaquin County <br />e ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br />(Signed) .............................-•---............. <br />.. .... �i ---(Owner and/or Contractor) <br />I By:.- i 'j.C(__(Title)- <br />(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side).. <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY.. -------------- <br />Y................ ... DATE ............ <br />REVIEWED BY = -- DATE-------- -------- - ......................... <br />BUILDING PERMIT ISSUED.-- ------..---. ------- - --- - -- ---- ----------------------- -------•--•---- DATE_. ............ <br />.-• -------------------- -.. <br />Alteratio and/or recom endations:------.._----------------------------•------ <br />1 31--� -- U ��a- -.----C�-------------- <br />....................................... .......------------------------------------------------ <br />.-----..--------- - ----------------------------------------------- <br />•------ <br />FINAL INSPECTION BY Date__...._ .-- <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />130 South American S+reo+ 300 West Oak Street 132 Sycamore Stree+ 814 North "C" S+raet <br />Stock+on, California Lodi, California Manteca, California Tracy, California <br />E5---9--2M-io=_2 Revised W-2100 <br />