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to SN t APPLICATION FOR SANITATION PERMIT Permit No, -------------- 5 (Complete in Duplicate) _ 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. /i - "'' Y1°-------------- JOB ADDRESS AND LOCATION------------ 1�J _�_L_�____��_a� �-ILL-�___ -- Owner's Name---------------•--------------------..-----tr ----W-----��Jl -1 - "----------------------------- Phone__-- ... Address-------------------- - �.e---------------------- ------------------------------- ------------------- 5_ �--------------- Phone--- --G--�V-------- Contractors Name------------------------------------- ----��'l,f- �!-�'.=-- - 3--- � f Installation will serve: Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ______;Number of bedrooms __. _ Number of baths _/--- Lot size' -r r Water Supply: Public system FV .Community system '❑ Private ❑ Depth to Water Table 7- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam-E] Clay Loam ❑ Clay ❑ Adobe pg, Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SpdDtic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material_______________________.___________-______-____- �E""" No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- D osal Fields Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line--,--------------- Number of lines-----------------------------------Length of each 1ine-----------------------------Width of trench-----------------:----------------- Type of filter material________________________Depth of filter material----------------- ----Total length________-___________--__-___________- ,� Distance to nearest lot line---Pit: Distance to nearest well-.�_O_f4_�_-_Distant r ,f�o�ndation----1 __________ � Number of pits---.-----------------Lining material_ r __Size: Diameter-_-_, -- Depth---- 2_4----------------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material__-___-___________________--.•__:_-. 1 ❑ Size: Diameter--------------------------------------Depth--------------------------- ---Liquid Capacity-----------------------------gals. k Privy: Distance from `nearest well__-___________-________________________________Distance from nearest building________-__._._________.._________--_ 'r ❑ Distance to nearest lot line------------------------------------------------------------- -----•---------------------------------------------------------------------___ Remodelin9 and/or repairing (describe): ------------------------------------------------------------ ------------------------------------------------------------------ ---------------------•--------------------------------------••-•--------•-- - 11 - ------•-- --'fa --------------------- ---------------------------------•------ - ---- ---------•-------- -I hereby certify that I have piepared this application and that the work will be done in accordance with San Joaquin County 4 ordinances, State laws, �sFid`rules and regulations of the San Joaquin Local Health District. • (Signed)---- I1__ ''� �pyy dd,---- r ------ F Contractor • - __ BY• '+ ---------------(Title) (Plot plan, showing Ez o Ivt, location of system in r anon to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY, APPLICATIONACCEPTED BYE,__---------------------------------------------------- --------------------------------------- DATE -- -------------------------------------------------- REVIEWED BY----------------------------- ----- -------------- ----------------------------------------------------- DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------•- DATE-------------�"""'.----------------------------------------------- Alterationsand/or recommendations-------------------------------------------------------------•-----------------------------------------------------------------------------------__-------- --- ----- - ----- -- --------------- -- -------------------- ------ --•--•---------- - ------------ 1 ---------------------------------------------------------- ----------------- ------ ------------------------------------------------- ---•--------------- ------------- w ------------ ------ ----- - ---- ----------------------------- --------- ' 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 6-51 Revised W-2100