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--� - APPLICATION FOR SANITATION PERMIT Permit No. 5 ----- V (Complete in ZZqquinDulicate] �/ Date Issued _----Application is hereby made to the San Localt is ict for a permit to construct and install the work herein described, This application is made in compliance wit n rdina JOB ADDRESS AND LOCA ON'�- ----/W------ �T- - ----------`� ----------------------------- -.--------------------- A Ph6ne'- Owner's Name--------- U-------•------ Address-------------- - - - --------1= . � C -- Phone----------------------------------- Contractor's Name----------------- , y Installation will serve: Residence Apartment House ❑ Commercial ❑ TraiEe Court ❑ Motel ❑ Other 5 '9t�. 1.17 J-'P_:a---------------------- 1 of living uni s,:' --� Number of bedrooms _- __-- Number of baths Lot size -_- - Water Supply: Public system Community system ❑ Private ❑ Depth o Water Table � ft. Character of soil to a depth of 3 feet: Sand F] Gravel ❑ Sandy Loam ❑, Clay Loam El Clay ❑ -Adob�~Hardpan ❑ n , � . Previous Application Made: Yes El No New Construction: Yes �No`❑� PHA/VA: Yes No TYPE OF INSTAL LATIOI�T7AND`'S,PE'CIF[CATIONS: t (No septic tank or'cesspool permitted if public sewer is available within 200 feet.)j i r Material _ 'IF --------- Septic n : Distance from nearest well Distar}c� from foundation__ ------------ -- No. of compartments_-__-. - Size -:-Liquid depth_----- _ _-Capacity_-----Q--- -- = Disposal Feld: Distance from nearest well-____--. Distance from foundation_-_- Distance to nearest lot line�____ - Number ofF.lin js----_.___- c .____----Length of each line--__ 7_ ------ length__--_ ----1 � Type'of filter materia--- - e .ISeepage Pit: Distance to nearest well--- >_----__Distance f om #oundation-_-� ____-_--.Distant to nearest lot ne-__ ---- ___-_� __-Linin material___-'-_ K.Size: Diameter----Depth---- -1- - Number'aflp�ts.- ��^----- g, fes"- - � Cesspool: Distance from-nearest well-----------------Distance from foundation------------------- material___---._.--_---.-__------__.---_gals. ---__-_Li Liquid Capacify-. gals. ❑ Size: Diameter---�=--------- ------- ---- ----Depth------------ ---------- ------ ------ - q p Y-------- ------------- Distance from nearest,building---- Distance uildin ---------------- Privy: Disfance-fromEnearest.weil _- _: g--- -T ❑ Distance to nearest lot lire__----___---- p Remodeling and/�r 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 Y ordinanc a e;law and r nand regulations of the San Joaquin Local Health District t ' (SignedVV -------------------------------------------------------- --------------------------------------------------(Owner and/or Contractor) I $Y� ------------------------------------------------------------ (Title) ------------------------ ----------------- l (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 I P. a r---A0 DATEr ---------------------------- APPLICATIONACCEPTED BY--------- -------- ---------------------------------------------------------- REVIEWED BY -------- ------ --_------------------------------------•---------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT'..ISSUED----------------------f- - DATE — ------�- I Alterations and/or recommendations:--------•-------------- ----------------- -------------------------------------------------------------------------•-- ---------------------- ------------------ --•----------------- --------------------- ---- ---------- --- - --------- -----------------------------------On--------------------------------------------------------------------------------- FINAL INSPECTION BY: ------------ --- - Date-- 0----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Am132 Sycamore Street 814 North "C" Street erican Street 300 Wast Oak Street Y 'r Stockton, California Lodi, California Manfi ca, California Tracy, California > ES-9-21A Revised 1.57 F.P.CO-