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APPLICATION FOR SANITATION PERMIT Permit No. 0 (Complete in Duplicate) Date Issued __--� _._y �3 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 �_g JOB ADDRESS AND LOCATION--- ------------ *�--- _4__-•--•------ _��_o�' - --------------------------- Owner's Name-----------------------------------------tom/" Phone . _7Z _,�------ AddreAddress ss------•------------------------------------------------- --------------•--•------------------------------ '` Contractor's Name----------------------------- �------ � L�-•---------- ---------------- Phone-------,,9---f-45_--�?7- --- Installation will serve: Residence% Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ IQ--P---- --------- - Number of living units: ___I___ Number of bedrooms __� Number of baths __/_. Lot size ____.____e�______ Water Supply: Public system ❑ Community system ❑ Private, . Depth to Water Table r34_rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R[ Hardpan ❑ Previous Application Made: Yes ❑ No�� New Construction: Yes ❑ No ❑ �x ��.. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Flocnal T `1k: Distance from nearest well-________________Distance from foundation--------------------Material-___________--___.__________...--------------- . No. of compartments--------------------------Size-----------------------•--------Liquid depth--------------------------Capacity----------------------- Reid- Distance from nearest well---- ------------Distance from foundation_______________ Distance to nearest lot line--_____________-. Number of lines-----------------------------------Length of each line-----------------------------.Width of trench--------_-------------------------- Type of filter material------------------- of filter material-----------------------Total length____________-____.-____________._______-. Seepage Pit: Distance to nearest well_1_O.4--------Distance fro. yfo�ndation_f-0-p_r---.Distance to nearest lot line__.�_Ur._____ Number of pits_______Z_.__________Lining materiali��4....Size: Diameter_e r t�-------Depti�__ - `_________________ Cesspool: Distance from nearest well-----------------Distance from foundation---------------.___Lining material___ _-_____.______'__--_____-_ ElSize: Diameter--------------------------------------Depth---------------- ------------------------ - --------Liquid Capacity----------------------------gals. Privy: Distance from nearest well__-_______________ _________________________Distance from nearest building------------------------------------------ 11 Distance to nearest lot line---------------------------- ----------------------------------------•------------------------------------------------- ---------------------- Remodeling and/or repairing (describe)=--------- ------------------------------------------•------------------------------------------ ---------------------------- --------------------------------•--•----------------------------------•------------------------------------------•-------------------•-•----•-----------*....................................... ------------------- -------------------------------------------------------------------- ----------------------------------------------------•-•------------------------------------------------------------•--•------------ 1 hereby cer4ff tna have repared this application and that the work will be done in accordance with San Joaquin County ordinances, States, an rules and re ulafions of the S Joaquin Local H falth District. rSi ned ----------- ------ --- ----------------------------------------------(�dhraErWimr*Contractor) ( 9 )--------------- --- - - By:------------------------------------------------------------------- --------- -- -- -lam----------•- ----- ---- -------tide)------ ------------------------------------------------------ (Plot.plan, showing size of lot, location of system in rel n to wells, buildings +c., can be placed on reverse side).• FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY---- ------------ --- - ----------------- ---------------------------------------- DATE--14 r--. J ----------- REVIEWEDBY-------------------------------- ---------------------------------------------------- -------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------------•------- Alterationsand/or recommendations--------------------------------------------- ---------------------•--------------•------------ -•---------------------•------•---•---------------------------- ------------------------------ -------------------------------------------------------------------- ------•---• ---------•-----------------•-•-------•..--------.--------•----------- ----------------- --------------------------------- ------------------------------------------------------------------------•--------------------------------------------------- ------------------------------------------- -----------I------------------------------------------------- --•-----------------------------------------•--------------------------------.----- ----------------------------------------------------------------------------------------------------------------------------------------- ---------- = ---------------•----------------------- ----------- -- ---- ----- --- - FINAL INSPECTION BY: ------- 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 Manteca, California Tracy, California ES-9-2M 10.52 Revised W-2100