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APPLICATION FOR SANITATION PERMIT Permit No. _ _�__• ._.3_.. (Complete in Duplicate) 6 Date Issued ._�� --- ib �"w 26 'A' pplication 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. ,#fJO8 ADDRESS AND LOCATION.____ -_-�-J__-_-117: _ _ - Q_ Zl� Owner's Name------------------------ T 2 ------------ U�_G6LE� Phone �p �a Address. = �-#_ v Contractor's Name L -------------------- Phon - --------------------------------- - - - - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---� Number of bedrooms __ Number of baths ._l____ Lot size -------- a x_ �6 Water Supply: Public system ❑ Community system.❑ Private Depth to Water Table --�___ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 17101' Hardpan ❑ Qp Previous Application Made: Yes ❑ Noj�' New Construction: Yes X No E] i TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Z Septic Tank: -Distance from nearest wellCJ 'Distanc from foundation-----�_0---------Materi �____/�-9_Y__c-"-"" No. of compartments------------- --------Size---- -. __�Z�4..S.___Llquid depth-------- -�?_-----Capacity--- _ �".. l Disposal 561d: Distance from nearest ---.-Distance--.-Distance from foundation_____�-b_r. _______Width of trench ___...Distance to nearest lot line_____•�"+---- Number of Length of each line_________�a lines_____--"_ �" __ 1f 'I� Type of filter material._" Depth of filter material---------1� _____Total length-------.--.-`7.- _ -------------------- Seepage Pit: Distance to nearest well___------------------Distance from foundation--------------------Distance to nearest lot line___-_--._________ ❑ 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-.___.._____-________-__ ❑ 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, State laws, and rules and regulations of the San Joaquin Local Health District.. (Si ned t 9 ).-- -- ---`-`-- ---------------------(Owner and/or Contractor) BY: ------------------------------------------------------------(Title)---------...---------------•----------------------------------- (Plot plan, showing size of to+, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- ------------------------------------------------------- DATE-----------•------/ - V �-,---�-�---------- REVIEWl=Q BY. -- - ---- -------------- DATE - ---------- BUILDING PERMIT ISSUED-------------------------------- DATE Alterations and/or recommendations------------------- --------------- ---------------------------------- ---- ------------------------• --------------------------------------- -- r 1yFINAL INSPECTION BY:--- - --------------------------- Date Date----------------- -------- -- ----------- -------------- ---=-------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 SouthAmerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton-, California Lodi, California' Manteca, California Tracy, California E5-9-2M I0-52 Revised W-2100