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APPLICATION FOR SANITATION PERMIT Permit No. 5--- (Complete in Duplicate) Date Issued .�!' �-- -• Application is hereby made to the,San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. .----- ---- -•-- ---- -- ----------------------------------------- JOB ---------------- S ----- -•--- 4 JOB ADDRESS AND LOCATION_____ ---- -�- - ----- --•------ ---�--� � -7-5-2--f�' s yI - ---- ------- - ------------------------- ------------ ------ Phone- --�----------:•-------•---- Owner s Name -pR-hw------ ]r _ #- V-------- _ - 0. 1�a x =°� �r- - --------------------------------------- Address------------------------ --- - Contractor's Name-----` ' --------------- Pone Installation will serve: Residence A artment House ❑ Commercial ❑ Trailer Court El Motel El Other ❑ . i crB ---_-------------------------- Number --_-----------------•--------Number of living units: ---/--- Number of bedrooms .-- Number of baths �___ o-s'xe ____--.-1--_--•--- Water Supply:' Publicsystem ElCommuhity system [IPrivate.:%.. Depth to Water Tab1eSD__•ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy 1.Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No. New Construction: Yes No ❑L FHA/VA: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No sep+ic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: � Distance from nearest w+el4_/ - - n--- Q� Material_G% �'t?/t - ; - __.__ foundatio No. of compartments----- +----------- Size_19,t - -----------Liquid depth------"r --- -----------Ca acit 6-O; ........... I '_._-_-_-Distance to nearest lot line_ ____________ Disposal Field: Distance from nearest welLl-g-- ______,Distance from foundation_.:_ Number of lines___.;'---------------- L ngth of each line__9� -------------------- of trench---A`��--------------------- y yam;: e s g O • pth of filter material__ - -----------Total len th_.f- ----------------------------•-•-- Type of filter mate rial_1_-�_____ _ „ . ......: Seepage Pit: + '. Distance to nearest well-~:- -------------Distance from foundation_____________4-__..Distance to nearest 4ot line___:_-,.:_______. ❑ Number of pits Lining material = _---- -=--Size: Diameter---------------- ------Depth--------------------------------- Cesspool: Distance from nearest well------------------Distance from foundation-------------=------1 fining material___,__.-------------11-1 ElSize: Diameter------------------------- - --------Depth---=------------ -------------------------------Liquid Capacity------------------------- gals. Privy: Distance from nearest well----------------------------------------------- Distance from nearest building------..____.____-_---------------------- Distance to nearest lot line-----= ------- --------------------------------------- --------------- - ------------ - ------ ----- -- ----- : L�t� Ren•ko ling and repair-ng ascribe):_=-�- ------------- ----- ---' --- - " r ---- 1 hereby certify that I have prepared +his applica+ion and that the work will be done in accordance with San Joa uin County _ _ _ _ q ordinances, State laws, and rules�and ra�jg�uiha+ions of the San Joaquin Local Health District. [Signed}_ ----------------------- -----------f------- --.j ... (Owner and/or Contractor) By:-------•------------------------------------- ------ - ----------------------------- (Title)------- ' e)---------------------------•------- ----------- . ----------- [Plo} plan, showing sire of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__: =----------- DATE_ '' . ----------------------- .r --- ---- --------------------------------------------- REVIEWED BY----- ------------------------------- ------------------ ------------ ---------- ------------------------- -------:-- DATE-------------------------------- ---- -------------•---- - BUILDINGPERMIT ISSUED------------- •------------------------ -------------------------------------------------------------------------------- DATE--------------------•------------------ ------------------ t Alterations and/or recommends+ions--------------------------------------- ------ ---••--"-----•--------• --------------------------------------- - R -----••---------- •---------------------------- ---•------•------ ---------------------------------------------------------- ----I------------------------- ------------------------------ ------------------------------- -------- ------------------ s f 5-- ------------------------------------------------ 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 Revisea 1..57 F.P,CO.