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f 'b �/ (� APPLICATION FOR SANITATION PERMIT Permit No. 5 (Complete in Duplicate) .S" ` � Yj 5' o" Date Issued }� � 4 1. f App1hcafion is herebymade to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is mde in compliance with County Ordinance No. 54,7. JOB ADDRESS AND LOCATION_ -------- Owner's ----- --------------------------------------------------------------- Owner's Name------------ --------------------- --_-- Phone.--------------------------------- Address - --------- Contractor's Name `" d� �---elly t�----------------------------- Phone f �-�-�-- Installation will serve: Residence E�•]�Apartment House ❑ Commercial ❑ Trailer Court [-] Motel Other ❑ f-- Number of living units: _-_ __ Number of bedrooms j---- Number of baths __ __ Lot size _____{ ____________________ Water Supply: Public system [Community system '❑, Private•❑ ..Depth to.Water Table ________ ft. Character of soil to a depth of 3 feet:; Sand Gravel E] Sandy Loam Clay Loam E] Clay ❑ Adobe Hardpan ❑� Previous Application Made: Yes E] No [KNew Construction: YesNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu0ic�}isev*is available within 200 feet.) Oki Septic Tank; Distance from nearest well-- ' !4_-_Distance jfrom foundationf_/_�__!------Material_____________________________________---_----. r- No. of compartments---------------- ---- -Size--- ----------------------Liquid depth--------------------------Capacity------------------ DispoosJal�F' !d: Distance from nearest welwo--- -�-Distaanc�e�fr�om foundati __n__ ___ __________Distance to nearest lot line_____ 1G' j Number of lines------ Length of each line____ _______ ____ Width of trench___.. Type of filter material_ Depth of filter material-__ ---------Total length_-- --60----------------------- -- Seepage Pit: Distance to nearest well-------------------- _Dr Distance from foundation- to nearest lot line_________________ ❑ Number of pits----------------------Lining material------ _:O___-------Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance from nearest well----------_------Distance from foundation-----------------.Lining material_-________________________________ ❑ Size: Diameter-------T--------------.---------------Depth------t,.:-----------------•------------------------Liquid Capacity----------------------------gals Priv Distance from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lot line-------- ____ 4___ -- -- -- - - - - Remodeling and/or repairing (describe):-------------- ------- ----- r r ------------------------------------------------------ ----------- ---------------------•--------- -------------------------_------------------------------------------------------------------------------------------------------------------------.-.- ------------------------------ 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 ao regulations of the San Joaquin Local Health District. s ; (Signed)--- d�il__�� f� -- -- ------ ------- -----------.--------- ---------------------------------- { and/ Contractors E BY:. --- ---------•--------- (Plot (Title} -2 _ (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 ------------- REVIEWEDBY--------------------------------�---------------------------------------------------------------------------- DATE----- BUILDING PERMIT ISSUED--------------------------------------------------------------------------------- -------------------- DATE_---------g1 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 r ES-9-2M 8-51 Revised W-2100