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{y J APPLICATION FOR SANITATION PERMIT Permit No.5---V (Complete in Duplicate) Y �' Rate Issued �_�_�_�____� •� ', k 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.�5,49). JOB ADDRESS AND LOCATION-------_-- e-- ---- ---------- ------.- ----- ----- -__-- Owner's Name------------ --•---- -- r" ---------------------------------------- Phone----•------------------------------- Address----------------•-------------------- t Fa Contractor's Name------------------ -_ - Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Tra'iler Court ❑ Motel ❑ Other ❑ < FNumber of living units: _l_____ Nu 'aer of bedrooms __Number of baths ____-__ Lot size _____ _ ,r __ ____________ Water Supply: Public system Community system ❑ Private E] Depth to Water Table.-"/Off. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe4.Q_�Hbi•dpan ❑ Previous Application Made: Yes ❑ No [rte-blew Construction: Yed_L;—NO' _❑ fi TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest 11 well-_�'-)MaDistance fro foundation---1- __ Material___ _�__-_---_- No. of compartments___-__'�.r- _____-Size___l1�"�-__U___a�____.Liquid depth__________�_------_____Capacity--------------______-_ Disposal Field: ,Distance from nearest well__f1 V Distance from foundation-_1 __ "'__-Distance to nearest lot ` Number of lines--__________)_________ _________Length of each line______- �/ 9 ��tr-'-------Width of trench --------� -------------- Type �• of filter material_&'7 .____:Depth of filter material_j__�_____---------Total length_____ " See pap a Pit: Distance to nearest well____0-Ci______Distance from foundation_______3 ___________.Distan ce to nearest lot line___--_ __----____ Number of pits--------/-----------Lining material---e-_jei t______-__.Size: Diameter____-_�_ ___ Depth------------- ------------------ Cesspool: Distance from nearest well------------.----Distance from foundation-------------------.Lining material------------------------__________--. +� ❑ Size: Diameter__________________ Li Liquid Capacity --------------------Depth- ---- -------------------------------------------- q - --------------------------gals.__ t Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---_____________-______________-___- ❑ Distance to nearest lot line----------------------------------'--------- -------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe :----- '.„+Gw ----• " '�= -.,: — • r ----------------------- ---- = F!--------.w--•. r4r--------------•'��------------' ' •+ " � ---------------•......---------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed). ---'------------------------------------------------------------- ----------------------(Owner and/or Contractor) By:_------------------------------------------------------------------------------------ --------------------------------------------(Title)---------------------------------------------------------------- (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------ --------- - 4�1---- `------- ------ ---------------------------------------- DATE-- -----f--- {-------- ----------- REVIEWEDBY------------------------------------- ---------------------------------------- ----- --------------------------------------- DATE----------- + BUILDING PERMIT ISSUED------------------------------------------------------------------=---------------------------------- DATE Alterations and/or recommendations--- ------- -- --------------------------------- ------------------------ ------------------------- -------------- ------------------------------------------------------------------------ ------------------- FINAL INSPECTION BY:----------- e_tNe Date-------- ,/X :• 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 4 ES-9-2M 8-51 Revised W-2100 I