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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 for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND i .----------•--L--O--CATION -':-"-_-_-_-'-j- l---//-�-j------�_._-----f-E+------ _----------------- - ,. ------------------ -------- Owner's Name -------- Phone_ - y— Address----------------------- �(1� ------4= �_ .. `' L ---- •---------� Contractor's Name - --------- ------ Phone .. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ ❑ Other ❑Motel r Number of living units: .-_� Number of bedrooms __y Number of baths --- ____ Lot size ----- Wafer Supply: Public system ❑ Community system ❑ Private [2� Depth to Water Table $0- ft. Character of soil to a depth of 3 feet. Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ® No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank ,, o � Distance from nearest well-----------------Distance from foundation--------------------Material __________.__________----_--_--_- ❑ /5r71- f compartments.---_____ 11 -- Size Liquid depth Capacity -_------------- Disposal Field: Distance from nearest well.... �__--_p / __ istance from foundation----(�-�_-----__.Distance to nearest lot line____-.---- ® Number of lines---------_ . __-_- -_ -- Length of each line-__+J_,�_ � Width of trench_____ }---- ---. -- -------------- Type of flier material_______1.�i1�'___---Depth of filter material-----1 "__--_7otal length___-_-- Q!---__- __ Seepage Pit: Dis#ante to-nearest well_____________________Distance from foundation-------.------------Distance to nearest lot line_- El Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth ------------------------ Cesspool: Distance from nearest weft-----------------Distance from foundation--------------------Lining material----------------------- --------------- F-1 Size: Diameter--------------------------------------Depth--------------------------------------- - -- -------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well-___________________________ Distance from nearest building ! ------- g----------------------------------------- ❑ Distance to nearest lot line______-__ r-----AQ---- Remodeling and/or repairing (describe):____---- , r 1 ` z t ---------------------------- �f r+a "'� -—-------------------------------------------------------------- ---------------------------------------•---------------- --------------- ---------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------- 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 and regulations of the San Joaquin Local Health District. (Sign ed}._RC1 J r - - ------------- (Owner and/or Contractor] $Y:--------------------------••--------------•-- Title (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side), FOR PAR ENT U ONLY APPLICATION ACCEPTED BY-----___, r_ -- ---- --- ------- _ ----------- DATE-----�---�.�------ ----- REVIEWED BY-------------------------------------- ----- ------- _ DATE -----------------------•- - -- UILDfNG PERMIT ISSUED----------------_ ---------------- - ---------- --"-------- ----------------------------------------------------------- :. _ DATEAlterations and/or rendations:-_ _- _--______-- ---_..___. ------------ �� ____ _-_______.__________________ ----- � a ----------------- `---� ------------------------------------------------------- ; ---- -- V -ff --- olipo.&14 0- i ----- f --- - E -------- --------------- - , ----- --- --------------------------------------- _ FINAL INSFECTION BYi-----------------r_•- 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 8-51 Revised W-2100