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APPLICATION FOR SANITATION PERMIT �Permit No.J.5 (Complete in Duplicate) / ate Issued,__,`_: Application is hereby made to the San Joaquin Local Health District for a permit c_onstruct and int th work rein described Ory�� Thhis application is made in compliance with County Ordinance No. 549. �d � � ¢ JOB ADDRESS AND LOCATION_ __ _ __±y Owner's Name______-_ .------ �� u�� `------------------ -------- Phone �,f -----"---- Address ' "'�- '�- -- _ - Contractor's Name----------ia- -$ / -�` ) ---- Phone `�'- - - -� Installation will serve: Residence Apartment House p Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: '� Number of bedrooms -:3--- Number of baths _/---- Lot size _19491'_X/-4_!p ' Water Supply: Public system ❑ Community system ❑ Private P?"6-epth to Water Table Z ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam �Cla Y Loam ❑ Clay ❑ Adobe❑ Hardpan+F; � Previous Application Made: Yes ❑ No 5a` New Construction- Yes [r7No ❑ - TYPE OF INSTALLATION AND SPECIFICATIONS: N (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` a { Septic Tank: Distance from nearest well-f-2--t---------Distanc from foun tion_ '� Ma�ten __al ----- - © No. of compartments_-:.; --_-____------Size- ------Liquid depth-__�It___---------- Capacity 1 ! Disposal Field: Distance from nearest weli"5D-__ _---.Dista.nce from foundation__ Distance to nearest lot line_3_',t.,�------ I Number of lines__tj_�__"____ ��1/ ___ "_-_-_ Length of each line_V2!'_ � idth of french-.2,9F "____ _________ �t- Type of filter material--_ s _ Depth of filter material_-_ ' j �-'�---------- Total length----��-�--T- --- ' Seepage Pit: Distance to nearest well----------------------Distance from foundation-"_____-.__________.Distance to nearest lot--li--ne---"-_-_-__-_-=-___-.-"-_-_-"-.-_- Ti Number of pits-------------- -----Lining material-----------------------Size: Diameter-- -----•--- ------Depth------------------ -------------- esspool: Distance from nearest well-________________Distance from foundation_-_-_-_-_ -__ Lining material -------------------------- EJ Size: Diameter----------------- ---------=---------De th------------- p Privy: Distance from nearest yell________ - --------- C:Liquid Capacity------------------ -------gaffs.. ________ -------- ______________________Distance from nearest buildin g Distance to nearest lot line_-___----------------------- Remodeling and/or repairing (describe)_______________________"___ _ ----- ---------------•----------- - ----- ------ -------------------•---- -------------------•------ ------------------------------ ---••------------•-----------------------•--------------------- -------------------------------------------------•-----•------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State law, and rules a d-regulatf�of the San Joaquin Local Health District. (Signe ------------ ----------------- -, (Owner and/or Cont t . ------ or BY' ---------- "- -- � [Title)-------------------- ` '" --- ------------------------- --- ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FO PA MENT E ONLY APPLICATION ACCEPTED BY----- -- __r--- -A---- " " .- ---------- -----------------------f -- - DATE__- �� - -- -- - IEWED BY --- UILDING PERMIT ISSUED------------------------------------------- ------------ ------ DATE - ---------------- ---------------•---•---- -------------•------------ -----. DATE--------- Alterations and/or recommendat ions:---- -------------------------------------------------------------------------------- --- ------------------------•--- - ------- - - -- -------------------------------------------- FINAL INSPECTION BY:...___________ ____ - - -----. �------------- ---------- Date" *Cl --- ��. : ,SAN JOAQUIN LOCAL HEALTH DISTRICT_ 130 South American Street 300 West Oak Street '132 Sycamore SStreetT- 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M J0-52 Revised W-2100