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APPLICATION FOR SANITATION PERMIT Permit No. _5______..�r �✓ ,tJ" � (Complete in Duplicate) ! t V 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. JOBADDRESS AND LOC,ATIIO,N.____;V ----- � ------------------------------------------------ ------------------------------------------- - Owner's Name.-f Vii =- �% ?' :_ c _= Phone. - ' Address .. . .. .. 0r^ ---------------------------------------------....------------------------------------ ------- C� �� ----- Phone :_------------------------- Installation d 2 6 Contractor's Name = -- ----------------------------------- Installation will serve: Residence 1Z 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms __a- Number of baths __.�___ Lot size ------- -�X/a-a - Water Supply: Public system Community system ❑ Private [3 Depth to Water Table �.�7 ft. Character of soil to a depth of 3 feet: Sand ❑ s Gravel E] Sandy Loam E] Clay Loam E] Clay E] Adobe E] Hardpan F]Previous Application Mader Yes ❑ No P New Construction: Yes X No ❑ , TYPE OFr INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well'&_ ___ ___Distance from found __ No. ocomartmnts- ___--_� ationf e p � -- -----------Size_SGl!�/d-�'s----. Liquid Disposal Disposal Field: Distance from nearest well&W4,dDistance from foundation---_ °_ _____._.Distance to nearest lot line--___ s____ ® Number of lines----------1--------------------Length of each line_-_----3� ----------------Width of trench----?:*!--"________________-- C 1 Type of filter material.____ Q_G1#------Depth of filter material---_Z V_`____.__Total length---.-_-_ F_---------------------- Seepage Pit: Distance to nearest wall?i l�,__Di,stance from foundation___ya_'__-t__ Distance to nearest lot line--- ` Number of pits---.--./--__-.-_____Lining material-4rw&,�......Size-. Diameter'___3- --_-----__Depth_____ -�-___________________ �. 1,� Cesspool: Distance from nearest well -----------Distance from foundation---------------- ...Lining material-------------------------------------- Size: Diameter------------------ _---._:.`---.De th---•-------------------------------------------------Li uid Capacity ------gals. Privy: Distance from nearest well._--- _____ _ ------------------------ __Distance from nearest building._-._______-_.--._------__._____---_._--. ❑ Distance to nearest lot line--------- ----------------------------------------------------------•----------------------•----------------------------••------------------ - 1 , Remodeling and/or repairing fdescribe):------------------------------------------------------------------------------------------------ ----•- - --------- ..._...--••-••-•-•-----•---- ----------------------------- ------•------------------------- ------------------------------------------------ --- ----------------------------------------------- - - "-- ---------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------•----•----------------------------------- I hereby certify that I have prepared tbis 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. (Signed)---- -- -- - ------------------------------- - -A-.-40wner and/or Contractor) By: ------------------------------ ----(Title---- 1 !. ---- --- - -- - - -- - - --------------------------- �� (Plot plan, showing size of lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- ------- ------------------------------------------- DATE--------- REVIEWEDBY---------------------------------------------------------------------------------------------------------- ------------- DATE BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE -- - -- -- -------------------- Alterations and/or recommendations:----------------- - -------------------------------------------------------------•-•----------------------------------••-- -------------------------.---------- ---------------------------------------------------------------- ----•---------------------------------------•-----..-•-----•--•----------------•-----------------------------------.....•-----------••----------------- -------•-----------------------------------------------------•------------------------------------------------------------------------ -------------------------------------------•---------------------------------------- ----------------------------------------- ---------------------------------- ------- - ------ -------------- ------------------------------------------------------------------------------ -- ------------------------------ -----------------------------------------------•----- --------------- ----- ---------------------------------•------------------•--••-----------------------------------------------------------•-••----------- FINAL INSPECTION BY----------- ---- Date--.-.-------- ------- ------ ----------------------------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M �0-52 Revised W-2100