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APPLICATION FOR SANITATION PERMIT Permit No, J (Complete in Duplicate) Date Issued -21-11152. Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal) the work herein described. This application is made in compliance with County Ordinance No. 549• JOB ADDRESS AND LOCATION________________2104---oast---5th-St, - - - - --------- wner's Name--------------------------- S._.1i �llf� '--------------------- --------------------------------------------------------------- Phone Address ----- --------------------------------•---•------- --------------------- Contractor's Name -----QW11 Z--------------•---------------- -- -------- -------- o ----------- ---------- ----------------------•--- Phone-----•--------------------- Installation will serve: Residence-n Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __-3 _- Number of bedrooms --- Number of baths ]_-___ Lot sue -----------6 Water Supply: Public system ❑ Community system '❑ Private,& Depth to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ] Hardpan ❑ Previous Application Made: Yes ❑ No [2 New Construction: Yesj] No ❑ 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--5P_1.------Distance from foundation---3-Q1---------MaFerial----C_OI Ile—t0 ----- No. of compartments__-.____2----- 5-..-------Liquid depth--------��------------Capacity-•---$Op--------- _________Size--------- 8 #- Disposal Field: Distance from nearest weft-----50_t---_Distance from foundation_-----5- �---------Width of french---------- r_t Type of filter material-------S.-2'.-------Depth of filter material------ $'l--------Total length--___•---�]Q_t-•_------_-- Seepage Pit: Distance to nearest.well--------------------.__Distance from foundation--------------------Distance to nearest lot line- _---- ❑ Number of Pits----------------------Lining material-----------------------Size: Diameter------------- --------- Depth- ------------------------------- Cesspool: Distance from nearest well--------------__Distance from foundation-----------.--------Lining material------------------------------ ❑ Size: Diameter Depth----------- r ----------------- --Liquid Capacit Priv � , _. .. ,,. �- = -- -.� Y: Distance from nearest well--------------------------------------------------Distance from nearest building 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 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, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- , -_SQMZatdn r_______ --------------------------------------------- DATE 2/11 2 REVII WED BY------------------ - �� -- -----------� -----...- - ------- --------- ---------- -- DATE_----- - ------ ------------------ ---------- --- BPILDING PERMIT ISSUED--------------------------------------------------------------- ------- - ------------------------------------- DATE -------------- A terations and/or recommendations__________________________ _ -------------------------------- --------------------------------------------------- ---- - -------------------------- FINAL INSPECTION BY:_ - Date —--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 5 cemore Street y 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ' ES-9-2M 8-51 Revised W-2100