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APPLICATION FOR SANITATION PERMIT -"Permit No. ,�.5..� ____-_ (Complete in Duplicate) I N Date Issued Tglica}ion 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 compiiance,with County /Ordinance No. 5449. JOB ADDRESS AND LOCATION - -..!_ l� �� Ld_tnQ. L-t.fi�. --------------------------•------------ Owner's Name____-- -__ -.. _/ _--- ' _ _E.1 �'` Phone. •- ---��)-- `' as ......... Address----- -------v. —Contractor's Name---- ------• ------- -- `Q �^ - ------------------------------------------------------------------------------•---- Phone_! ' _ - I' Installation will serve: Residence'( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms _ Number`of bathsLot size -------------- Water 1I Water Supply:`"Public'system [-]'""Community system ❑ - Private (` Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: l Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe C9. Hardpan ❑ , Previous Application Made: Yes ❑ No X_ New Construction: Yes X No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance f om nearest well___ [ ______,Distan/ce from fondation__�QI��.Material_ No, of compartments----- Liquid depth----� -------------.I _C___a_.Gpa Jcity_�Q___�_- I + - ---- Disposal Field: Distance from nearest well____ ___________°Distance from foundati�� '�.__.Distance to nearest lot [ Number of lines_-___- _______ __________________Length of each line__________._ __�.____ Width of trench--_ _ - : r �l__-___.. ,___________________ Type or filter-materials+_,__ ear Depth of filter material____j _...______-Total length------- ____________--____.__ SeepagilPit: Distance to nearest well-----------------------Distance from foundation:"_....-.___.h___..Distance to nearest lot line__________-__-.._ ❑ Number of pits-- ------Lining material-----------------------Size:,;Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------.----------Lining material-------------------------------------- Size: Diameter-------------------------------------_Depth------------------__ ------------------Liquid Capacity gals. Privy: Distance from nearest well.._.__________`,_-_-___.____---------------f--Distance from nearest building__ --------------------------------------- Distance .-_______.______---______._Distance to nearest lot line-------------------------- _ Remodeling and/or repairing (describe)=--------- -------------------------------------- ------=--- ------- ------------------------ - S - - . . _________________________________________________________________________________________________________________________________________________________________________,__-____-.-____-__.-___________-_-_,-___________--._ 4 E # -_-___ ____________________________________________________________________________________________•________________._--______________--._ t F b 1 I hereby certify that I have;prepared this application and that the work will be done in accordance with San Joaquin County ordinanc4Stafe and rules and-re ulation oft an Joaquin Local Health District. Si ned ------- ---•--------- ----- Owner and or Contractor( g ) r-moi I / l - - - - - ------------ _... Tit a •------------------- ------ ----------------- ----------------- (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-----A4--- -- `------------------- DATE---- � REVIEWED BY t r DATE_ BUILDING PERMIT ISSUED------------------------------------------------'-------------------------------------------- •----- DATE----------------------------------------------- -------------- Alterations and/or recommendations--------------------------------- ------------------------------------ ------f--------------------- ------------------ ---------- ----- ------------- ---- - -- . ---- -------------Y-------•--.-.-- --------------------------------•---•------------------ ----------------------------------------------------------------------- } -- ------- ---------------------- ----- 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 '1 ES-9-2M ; Revised W-2100