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Permit No. 5 APPLICATION FOR SANITATION PERMIT a'1 (Complete in )li Dupcate - w ;,- 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 wjith, Count f Ordinance No. 544 JOS ADDRESS D LOC TION_ l--I- ------------------------------------------- --------- ; --- Owner's Name.-!f(- ------- ----- -------- ------- ---- - - -------------- -- --------------- - -- --------------- --- A -- --- ------------------------ ------------------------------- --------------------------------------------- Address Contractor's Name----- -------- ------ Phone---------------------------------- ----------------------------------------------------------------------- Installation will serve: Residence Rr Apartment House ❑ Commercial ❑ Trailer Court ❑ QQMo9tel ❑// Other ❑ Number of living units: mber of bedrooms -3-_ Number of baths _1---_ Lot size _ la--- -1__. ---------------------------- Water Supply: Public system Community system '❑ Private ❑ Depth t Water Table -------- ft. depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ *� Character of soil to a dep ❑ �$ Previous Application Made: Yes ❑ No V New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or cesspool permi+ted if ublic sewer is available within 200 feet.) n {.1---_.Mate ial_ Septic ank: Distance from nearest wel istanCe f� m fo�nXda ' n___--___-- - �.�—� No. of compartments----------- ----- - -- ize-1 •--- - Q?Liquid de h: Capacity--�� Disposa Field: Distance from nearest w istance from foundation---_ - ___---Distance to nearest to li �� Number of lines----__----_- t-- Length of each line---------------- fr-----.Width of trench_-_- _- t___-_----------- 7ype of filter mat --� epth of filter material------ - ---------Total length-----__--- ------------------- Seepage Pit: Distance to nearest well----_____--_--.--- Distance from foundation--------------------Distance to nearest lot line__--_-_---------_ El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth---------------------- ----_-.--_--_-- Cessp ool: Distance from nearest well-----------------Distance from foundation-____-.----x---.-_----------------------- Lining material------------------------------- _----__--__ _a_s- Size: Diameter Depth .tUquid Capacity M: Privy: Distance from nearest well --------- ---- ---__ --------- ---Distance from nearest building------------------------------------------ Distance _------_ -----__-----_--- _----__-.Distance to nearest lot line--------------------------------- ------------------------------------------------------------------------------------ ----------------- Remodeling and/or repairing (describe):------------------------------------ ---------------- -------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------ ------ •------------------------------------------------- --------------------------------------------------- ---------------------------------------- - I hereby certify that I have prepared this.applicafion and that the work will be done in accordance with San Joaquin County�� -- ordinances, State laws, and rules and regulations of +he San Joaquin Local Health District. [Signed} GU G1 ------------------------------------------------------------- ----------------------------(Owner and/or Contractor) B ----- ------------------ --------------(Title)-------------------------------------------- ------------------ ------------ - ----------------- --- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------- DATE"1--------------------------------------------•- — REVIEWED BY--------------------------------- DATE -------- BUILDING PERMIT ISSUED--------- ---- ------ DATE--- ------------------------------•------------------------ Alterations and/or recommendations--------------- --- ---------------------------------------•---------------------------------------------------------- --------------------------------------------------------------------------------------------------------- --------------------------------------------- --------------------------------------------------------------------••----------•-------- ------------------------------------------ -------- ----------------------------- - 1 jDate �. / s ---------------------------------------- F1NAL INSPECTION BY:-.------------------- ------------ 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 B-51 Revis 1 W-2100 ,�