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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) 6 Date Issued 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. JOB ADDRESS AND LOCATION----- � ,� -------r "-- le fin S Owner's Name---------- PC` Pone / L�� Address = ----C •-.`ter =---____-- !--' 1- -------------------------------------------- --------- -- ------------------- ----- Contractor's ontractor s Name------- - - Phone------------------------------- ---- � -----Installation will serve: Residence [ ] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __2rNumber of bedrooms -Y-_ Number of baths _A_ Lot size _____f` - ------A-------- l_ 3 .- Water Supply: Public system E] Community system -F] Private �epth to Water Table 64 ft. Character of soil to a depth of 3 feet: San . Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sepfiic'T Distance from nearest well Distance froy� f unon____________________Maf real____-_--___._____- ____._______ _ . ter/ _ __J___�-_--_Liquid depth _____---_-_ Capacity No. of compartments------_T�I�_�____s�_______Size--,�-�-- �. q p � , ----- -------�. --- Disposal Id: Distance from nearest well!- ----------Distance from foundation___'-_'0--------Distance to nearest lot line____'p_____ Number of lines_-----_____f-'- ---_-____-� _Length of each line---------- --b�__---Width of trench-------1f�-----+��''-------------- Type of filter material__r -'� ,_Depth of filter material_____1, ____:.-Total length_____________ _a_______________•- Seepage Pit: Disfance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-------.._______- ❑ Number of pits______________________Lining material__-_--__---___-__ __Size: Diameter-------------------------Depth ___ ssp Distance from near t we ___ ________-_ istance frooun atio --_ Lining material_ -------------------- Ce DstanDc'e frofimrnearest well----------------------------------- Privy: jD=� - Distance from n�res}IpacityF T- __- .__gals building------------------------------------------ n --------- --- ---- ❑ Distance to nearest lot line i i 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 ordinance tate laws, an rules and regulations of the San Joaquin Local Health District. (Signed - ----- -- - - ---- ------------------------------------------------------------------------------------------- ------(Owner and/or Contractor) B -------------- --------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plo n, showing size of lot, location of.-system in relation to wells, buildings, etc., can.be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY------ ------ --------- ------ DATE---------- ----- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE---- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:-------------------------------------- ---------------------------------------------------------------------------------------•-------------------- : --------•-...--- - 1-1-5 ------�'--�-��-�-- -------� '--t--- ------- = -------------±---�------ 4 -------- ---- � h ----- ------- ---------- - ------•------------------------- --------------------------------------- ----------------------------=----------------------- =-------------------------------------------------- -------- -------------- ----- FINAL INSPECTION BY:------ -------- -~�� SAN JOAQUIN LOCAL HEALTH DISTRICT f 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street t Stockton, California Lodi, California Manteca, California Tracy, California ES----9--2M 5-51 Revised W-2100