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S APPLICATION FOR SANITATION PERMIT Pe it No. (Complete in Duplicate) Y/Y/ 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. 5 JOB ADDRESS AND LOCATION----------�?--- - ------- Owner's -----Owner's Name--------------------------------------------- Address------------------------------------------------------ --H--C`l"7! ,tom _-_ Contractor's Name------------------------------------�.0 Installation will serve: Residence jX Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___/__ Number of bedrooms __ Number of baths J----- Lot size --- ./._Q--_____________ ___ Water Supply: Public system Jg Community system E] Private ElDepth to Water Table Oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay am ❑ Clay ❑ Adobeg Hardpan ❑ Previous Application Made: Yes ❑ Noj" New Construction: Yes ❑ No ❑ • TYPE INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic T84.. Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- AAT No. ____-_-_----------____________-_-----_________- No. of compartments--------------------------Size--------------------------------Liquid depth_-.-----------------------Capacity---------------------- posal Hd: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line-------.--------- �( j Number of lines-----------------------------------Length of each line------------------------------Width of trench ------------------------------ V Type of filter material-------------------------Depth of filter material----------------------- length------------------------------------------ Seepage Pit: Distance to nearest ell_.40-440fo ndation---/� line-'*.___.Distance to nearest lot line0—. Number of pits------- --------_-Lining materiaL `f�_.Size: Diameter.... Depth- Q_!__________________ Q Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---_(( ---------------------------- I ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------- -----------------Distance from nearest building------------------------------------------ ElDistance to nearest lot line--------- -------------------------------------------------.-.........--------------------------------- -------------------------------- V Remodelingand/or repairing (describe):---------------------------- --------------------------------------------------------------------------------------------------------------------------� ------------------------•-----------------------------------•-------------------------------•-------------------------------------------------------•---•-------------------------- ---------------------------------- -----------------------------••-------------------------------------•-------------------------------------•-----------------------------------------------------------------------------•------------------------------------ -----------------------------------------------------------------------------•------------------------------------------------------------------ ---------------------------------------...--------------------------------- 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 rue and regulations of the an-oa'quin� ocal Health Disstict. (Signed)--4sh ' J��` -- ------ ------- ---- .. -j----�= ----------------- (Owner and/pr Contractor) 6- --------- --� ? ---- - ----------------------------------------------(Title) Q , --------------- {Plot pla g sizeof lot, location of syste in relation to wells, buildings, etc., can be pl ced on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B` - --------------------------------•- ------------------ ---------------------------------------- DATE'S-r REVIEWEDBY--------------------------- -- ----- -------------- -------------------- ---------------------------------------- DATE---= '- -------------------------------- BUILDING PERMIT ISSUED-- --------------------------------------------------------------------------- DATE- Alterationsand/or recommendations:--------- --------- ---------------------------------------------------------------------------------------------------------------------------------------- --------------------- ------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY---- -------------1u�� --- ----------------------- Cate ----------�� ----oil----- �1-------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manfeca, California Tracy, California ES-9-2M 8-51 Revised W-2100