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APPLICATION FOR SANITATION PERMIT Permit No.�... ---___- (Complete in Duplicate) '. f Y `5~ t Date Issuedr Applice{ion is hereby made to the San Joaquin Local Health District for a permit to co strut+ and install the work herein described. This application is made in compliance with Coun Ordinance No. 5.5 ! E - JOB ADDRESS AND IOCATlO ----- - --------- -- -----& cw Owner's Name3 --- 9_7_,?-- - �• x ---- P e _.._. 'I Address ------------- ' l � . Contractors Name-----=---- - Phone------------------------------------ --------------------------------------------------------------------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---- Number of bedrooms - -__ Number of baths ---- Lot.si e ___-&CO-ax_1,S,S,---------------------- Water Supply: Public system ❑ , Community.s.ystem ❑ Private�J' Depth to Water Table J,57 ft. Character-of soil to a depth cif 3 feet: Sand E] Gravel ❑ Sandy Loam [X Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes E] NoJ New Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-_j14./____'Distance from foundation__JA.__ '._.Material_ L '----- __-_____. i No. of compartments ----Qt_____--Size__ _ _ __ __ - Liquid de th___/�_0_ /-___.___Ca aci �. p -----•---- q P P tY Y [> Number of lines__-.-_.______ _ �`/.Distance from�foundation__��r?_!____-Distance to nearest lot line._.._______ + `3--ca + Disposal Field: Distance from nearest wed_. �----il alength of line________,�___..___�,�____._.Width of trench__:.__-_.-_-�-.�______._ Type or filter material.:.t _-_.Z._..__ Dopth 6t filter material__�i-------------Total length___ _____ ____�-�_--�-______ Seepage Pit: Distance to pnearest well_ ___________ Di ante from foundation----- ___--------Distance to nearest lot line-_,__-_._________ l Number of its---------------------Linin material-----------------------Size: Diameter-----------------------Depth------------_-------------------- Cesspool: ` . 'r Distance from nen rest-well_'_s ___`Distance from.foundation. _-__ _ Lining .material_ __'__ __ Death - .' = Liquid Capacity! a r;9als._ Privy: Distance from nearest well---------------------------------------.__--____._Distance from neares+ building------------------------------------------ ❑ Distance to nearest lot line----- -------------...-`------`--=------- Remodeling and/or repairing (describe):--------------------------=---------------------- ` Q ----------------------------------------------------- ...--"-----------------------•----------•------•--------'---•----------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and-regulations of the San Joaquin Local Health District. (Signed)----- --- ------ --'- :.,...-�" ------------------------------- -- ------ -------------------=----------------------(Owner and/or Contractor By:---------------------'---------------------------- ------------------------------------------------------------------- -------(Title) - - --••- --- ------------------- (Plot plan, showing size of !ot'location of system in relation to wells, buildings, etc., can be.placed on reverse side). c- FOR DEPARTMENT USE ONLY ------------------ , APPLICATION ACCEPTED BY---..-- -- ------- ----- - --- ----------------- --- ---------- -------- DATE-------- ... 5 REVIEWED BY-------------'--�---------- - -'= '- ---_-- ==---- =. _ '__ ;,DATE_=____.• ,. - BUILDING PERMIT ISSUED---I-------------=---------------------- ----------------------------------------------------------- DATE----------------------------------------------------- Alterations and/or recommendations----------- ----------------------------------------------•------------------------.-----------=--•------`-------------------- -----------------------.------ y -----------------------------------------•----------•---------------------------------•----------------------------------•--•-------`----------------------------•---•------------•-•-------------------- ------'. ------------------------'------------------------•-- ------------------- -----•----•-=-------•---------'---------- ---•------------------------------;`---------------- •----- --- -- li Av FINAL INSPECTION BY:--^I- ---__ --- Date-:-----__r------- ------------- "SAN'JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 3 132 Sycamore Street 814 North "C' Street Stockton, California \ Lodi, California / Manteca, California Tracy, California ES-9-2M Revised W-2100 y1 ,