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APPLICATION FOR SANITATION PERMIT Permit No. ___Z_2,Y9_-- (Complete in Duplicate) 7 Date Issued .__ ��__ Applicaa-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 compliance with County Ordinance No, 5419. JOB ADDRESS AND LOCATI N------ .,, I� -AW,5-M----------------------------------------------------------------------------------- Owner's Name--le •------• •-------------------- ---------------------------------.. Phone-------------------- - Address-------------- � —� ly Q1g Contractor's Name --------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence IK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I___ Number of bedrooms _Number of baths ___f__ Lot size ------- _______________________ Water Supply: Public system Ep--Community system ❑ Private ❑ Depth to Water Table _45� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Pk 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 Tag: nce from nearest well------------------Distance from foundation---.___.__..------.Material--------------------------------------------- ❑ of compartments------ -- - -------------Size-------------------------------Liquid depth.-------------- - ------ -Capacity----------------------- Disposal Field: istance from nearest well-________________Distance from foundation--------------------Distance to nearest lot line-------..___..._. ber of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------------ 41pe pe of filter material_________________________Depth of filter material-----------------------Total length------------------------------......_...__ i Seepage Pit: Distance to nearest well.....N-4-7�—Distance fr foun�ation....10.-__-___.Distance to nearest lot line-- -----�. �. . Number of pits----/---------------Lining material is Diameter---- Deptn_._ �r�-e______. Cesspool: Distance frort nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 11 Size: Diameter --- -------- - ------ Depth-------------- -------------- ---------------------Liquid Capacity----------------------------gals. Privy-. Distance from nearest well------------------ _________.__---------Distance from nearest building------------------------------.__._____._. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------- ------------------------- Remodeling and/or repairing (describe):--------- ---------------------------- - ----..............-- --••-------------------•-------------•--••----•-•--------------------------------•---•-- •-------------•-------------------------------------------------------------------•------------------------------•----------------•------------------------------•----------• ..------------•---------------------------- i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, fat w , nd rules and regulations of the San Joaquin Local Health District. (Signed) -- ---- 47---. -•------------------------ ----------------- -------(Owner and/or Contractor) BY: - (Title)---- r-------- (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 DATES'------•--------------------• ------------------ REVIEWEDBY------------------------------------------------------------ ------------------------------------------------------ DATE---------- --------------------------- >- BUILDING PERMIT ISSUED------------------------------------ - ------ -------•--------------------------------------- DATE-- Alterations ATE-Alterations and/or recommendations------------------------- ----- -------------------- ------------------------------------------------ -------------------.------- -- ------ -------------I------------------------------------- -------------------------------- - ------ --------- ------------ ------------------ -------- --- --------------------------------- ------•------ •--------------------- -----I------- --------------------------------------- FINAL INSPECTION BY:----------- ---------------------------------- Date--------r------------Q._' S 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-- %-2M 149446 Arwono 12-54