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APPLICATION FOR SANITATION PERMIT Permit No, 5. - a 6`^ (Complete in Duplicate) Date Issued / 6 �Y - Applica{ion 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 Orcin7�ceAo. 549JJOS ADDRESS AN CATION__- /_3__3-_---&/'/0-a- '4 Owner's Name---------- ------- � 14/L/'�jV f:-- �� /u}`�pp.•`_ . Phone_ -.-Af1� _ Address >Tl ----------------------------------------------------- Contractor's Name Sf` ------------------ ----------- PhonelIXQ_4-_ A Installation will serve: Residence Apartment House ❑'l Commercial E] Trailer Court E] Motel [-IOther E]Number of living. units: _ri�Number of bedrooms __ __ Number of baths ___`YLot size _ �-) -!� _--__ -------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe lardpan ❑ a Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ `` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)PePr is Tank: Distance from nearest well-------------- --Distance from foundation--------------------Material___________.-_---_____-_______..._____.________. W 7("�,• -- No. of compartments------- -----------------Size_-------------------------_-Liquid depth--------------------------Capacity-------------------- �al„Fi d- Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line___________-_____ t/ Number of lines-----------------------------------Length of each line---•-------------------------.Width of trench-------------------------------•_-- ��-"'_��- 1111 � Type of filter material__._._________---------Depth of filter material-----------------------Total length------------------------------------------ Seepage __________________-_- -_____Seepage Pit: Distance to nearest well jAVI C____----Distanc fr n f undation...�_Q-�-_._.Distance to nearest lot line----- 7-7 Number of pits----I----------------Lining material_ __._ Size: Diameter__-- -'------- Depth__ _. `------------------ 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------ - --------------------------------------•------------•-------------------- ----------------------------------------------------------- Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------------- -------------- ------------------------- -------------------- --- -------------- ---•----------------------•-------------------------------- -------------------------------------------------------------------------------- ------------- ----------------- I here y certify that ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r le an re s of the an Joaquin Local Health District. (Signed)----------- --------- Y* .W_I S h C Contractor) ------ - By:....... --------- [7itle)_ °�rn D!"'. (Plot plan, showing size of lot, location of system in re ion to wells, bui Ings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ----------------- DATE------------ REVIEWEDBy-------------------------------------------- -------------------------------- -------------------------- DATE-------- BUILDING PERMIT ISSUED--------------------------------------------------- - - DATE. -- A terations.and/or recommendations----------------------------------- --- ________.__--___••_--_- ---------- ------------------------------ ------------•-----------------•-------- ---------- FINAL INSPECTION. BY------------ ----------eA?�/4 �/ / ....... -- - --• Date--------- - ------- ---------------------- 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 ES-9-2M Revised W-2100