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e. APPLICATION FOR SANITATION PERMIT Permit No. ........ ..I 2,, 3 (Complete.in Duplicate) a 3 S d L 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 OCATION---------------- -��- -- ----- r ------------------------------------ Owner s Name -•---- !� � --�'r � O ------ ------- PIi ne__,� '---- .-mac.-:�-:-------•--- - --------------_e -��°� - Addres .. ---- ....... - - ----------------------- Contractor's Name = Phone_ _..=:,�� -- Installation will serve: Residence \ Apartment House ❑ Commercial ❑ , Trailer Court r❑ Motel ❑ Other ❑ . Number of living units: _- _---- 'Number of bedrooms __�___ Number of baths -�_--_ Lot sizeF --------_--___-__ Water Supply: -Public system' Community system ❑ Private ❑ Depth to Water Table,l� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobp)n Hardpan ❑ Previous Application Made: Yes ❑ N�,k New Construction: Yeil� No ❑ \ TYPE OF INSTALLATION AND'SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tanj: Distance from nearest well-----------------Distance from foundation--------________-Material------_-------------------------_--_----____-__.. V-11,r�.tf No. of compartments Size: Liquid depth--------------------------Capacity----------------------- sposal Fel Distance from nearest well_________________Distance from foundation_____--_______-_.Distance to nearest lot line------_-_-_-.._.. ®� Number of lines-----------------------------------Length of each line------------------------------Width of trench.----------------------------------- Type ---------------------------- ----Type of filter material--------- -- ------Depth of filter material-----------.--,_ g -------Total length -•--------- 'J Seepa a Rit: Distance to nearest well-.,,"_'"------Distance' orr; foundation------- ...........Distance to nearest lot line-1~ Number of pits-___--------------Lining mater:al ____Size: Diameter__----------Depth.__ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material ___-_--.----_-.---_.--____--_------- ❑ Size: Diameter-----------------:---------r----------Depth----------------------------------------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------- ----_-_-_-_--- ❑ Distance to nearest lot Iine---------------------------- ------------------------------------------------------------------------------------------ ------- . modeling and/or repdiPi {describe: 6051/_71 ---•/�----� -- ---- ------ -- --------------------------------------------------------- ----------------------•---•---------------------------------------------------------------------------------------------------------------= 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 le and regulations San Joaquin Local Health District. g q (Signed) = i - --- -- By: = {Owner and/or Contractor 8 ••------••---•- {-- ---��----------- ----------------------------------- --- - -- - ------ ---------- Title -e-da--on � 'tr t (Plot plan, shaving size of lot, location of system in relation to wells, buildings, etc., can be ed on reverse side✓ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------- s .-- ---------------•------------------------ DATE------ -- REVIEWEDBY--------------------------------------------- --------------------------------- --- DATE.. BUILDING,PERMIT ISSUED------------._--••----------------------- •----------------------------- DATE-------------- ' Alterations and/or recommendations-------------------------------------------------------------------- --------------------------------------------------------------------------------------- ---------------------------•---•---------------------------------------------•------------------------ ---------------------- - ...--------------------------------------- -------- ---------------1--------------------------------------------------------------------------- ------------------------ ------ FINAL INSPECTION BY:. Date ---------- - SAN JOAQUIN LOCAL HEALTH DISTRICT t { 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C"-.Scree+ Y, Stockton, California Lodi, California Manteca, California .� Tracy, California, ES-9-2M 10-52 Revised W-2100