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APPLICATION FOR SANITATION PERMIT Permit No,5,5-y (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 LOCATION ------ ---- -- ---- __1Z11-------4ZAI_�_A-----------------'--------- Owner's ---------------1--------Owner's Name_.-------------•-------> --- ---------- ------------------- -------------- -------- Phone,----------------------------------- Address-.---------------------------------- - --------------------------------_------------------------------------ 4 4�0 Contractor's Name-------------- --ret,_4---- -- --------------- Phone__��._ _.6"_ - __-, Installation will serve: Residence Apartment House E] Commercial E] Trailer Court E] Motel ❑ Other E] Number of living units: __ of bedrooms 1-_Number of baths ;,--- Lot size ----------- ----------------- Wafer Supply. Public system ;�=unity system E] Private E] Depth to Water Table7-- I , -Lf ft. Character of soil to a depth of 3 feet: Sand ' Gravel Sandy L O'Clay Loam Clay E] Adobe Or-Hardpan E] an Previous Application Made: Yes 0 No Vo'�NeE] Sandy Construction: Yes No E] Clay 0 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: -if, Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- No. of compartments_-_----- - - ---------- ' e--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Distance from neaisfance from foundation-- -------------Distance to nearest lot line_______--- Number of lines____-_-..__ ----- -Length of each line-- ....Width of trench.____ ---------------- Type of filter mafer1al,:6_.,e_ Depth of filter material----- ....Total length-------- -------------- Seepage Pit: Distance to nearest weII4/4- .___Distance f m, fo ndafion____.,R)__`_._.Di Price to nearest lot line-/a------ Number of pifs_(��---------Uning mafe6 _ . ..-6ize: Diameter-2----------- .....DelA----- ------------- dfo-- A- Cesspool: Distance from nearest well-----------------Distance from foundation___._._____________ Lining material_____.-______----------------------- El Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity---------------------------gals Privy: Distance from nearest well-----------------------------------------------._Distance from nearest building--------------------- --- -❑ Distance to nearest lot line---------------------------- ---- ---- ----------------- 2/ •-------------------------I—--------------I-------------- Remodeling and/or repairing (describe):------------- --------- 4- --------- ;?-------------- --------------------- ..................-------I--------------------------------------------- ------- x ----------- --------------- --------------------------------------------------------- e - -- ---- ----------- ----------------- ----------------- ------- --- ------ --- ----- - -------- ---------- ----- -------------- ----------- -----------------•---...--------------------------------------------------------------- ---- ---- ----------- ----------------------------- --------- ��7 - --- ------------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I S, and rules an regulations of f San Joaquin L call Health District. "Laith i (0 nff and/or Zonfracfor) --- -------- --------- ----- ------------- 't (Signed). 7�� .. ... - - ----------------------------------------------------------------------(Title ----- wf By:------------------ --------------- 01 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13-6-, ---------------- DATE3;�--------------------- - -- ----- - -------------------------------------------------------*---- --- REVIEWED BY-------------- DATE ------------ ----------------------------------------------------------------------------------- ---------------------------------------- BUILDING PERMIT ISSUED----------------------- ------------------------------------------------------------------------------ Alterations and/or recommendations:-------------------------------------- - ---------- --------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- ----------------------------------------------------------------------------------------------------- ------------- ------------------------------------------------------------- ------------------------------------------ ------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- - --------------------------------- - -------------------------- ----------------------------------------------------------------------- --------------------------------- ---------- ------------------------------------------------------- FINAL INSPECTION BY:---------------------- ------------------------- -------------- Date-- .------------------ -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES—q-2M 10-52 Revised W-2100