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APPLICATION FOR SANITATION PERMIT Permt No.��- 5___t__U___... ` (Complete in Duplicate) Date Issuedt-0- Application i 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)499.. JOB ADDRESS AND LOTION... ----------------- ------------ OwnerName_ _ � — ------------------------------- Phone----- _ / e_ _ � Addre Contractor's Name ---- - - -c. ,-------------------------------•------------------------------------- Phone- Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____Number of bedrooms_= -N, o- I L Water Supply: Public system ---------------------- Community Commuritys sten El Private ❑ Depth to Water.Table ,5 'ft. Character ot34'(,�q itdpnth,rt ;•. -�^ ❑r- + .,, � ��P. .,p�c7 vrdver �cin�� Gam L.T-�k-ra'y coam LJ -,.iay L__l ^aoI-larapan LJ Previous Application Made: Yes ❑ NOX New Construction: Ye AA 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_________________Distance from foundation--------------------Material _____.________-__.____________--___..____-___--- y No. of compartments------ -------------------Size--------------------------------Liquid depth------------------- ._Capacity-----------------------E 3� Disposal Fiel Distance from nearest well---------------___Distance from foundation--------------------Distance to nearest lot line-----------------a Number of lines------------------------------- --Length of each line----------------------------- Width of trench----------------------------------- -�.i /1 Q Type of filter material-------------------------Depth of fi rial_---------------------_Total length----•--•---------------------------------- Seepage Pit: Distance to nearest well__�,E�'____Distan 1.11 m`_fo d tion_,{______'Distance to nearest lot iine___ _�____ Number of pits----/--------------Lining materi ------- �t---. ze: Diameter----- ---------------Depth_------_ -� - � llbe Cesspool: Distance from nearest well_________________Distanfrom dation-------------------.Lining material------------------------------------- r7l Size: Diameter----------------- -------- Depth--------------------- -------------------- - -----Li uA Capacity - 9 ----------- -- - --------gals. .. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-___._______________________.._____ ❑ Distance to nearest lot line------------ • Remodeling and/or repairing [describe] r -------•-------------------••------------------------------------------------------------------------------------•---- ------------------------- -----------------------------•--------------------•---------------------------------------.-...-•-----------------------•---------------------------------.------------------------------------ P ------------_ ____----------------------------- ---------------------------------------------_----------------- --------------------------------------------------------------------------------------------------------------- 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, an rules and regula ions of the San Joaquin Local Health District, i (Signed)...... . f�--- ----�--a �Y^"'` ------- ----------------------------=---------------------------- ------------ (Owner an � d r Contractor) � (Title) -7 t- ` (Plot plan, showing size of lot, ocation of system in relation to wells, buildings, etc., can be plon reverse side). ed FORD ARTMENT USE ONLY APPLICATION ACCEPTED BY--- -------------- - --- -- -----------------------------••-----•-------------- DATE----- -off REVIEWEDBY------------------------------------------------------------------------------------•---------------------------------------- DATE---- ------ BUILDING ----BUILDING PERMIT ISSUED--------------------------------------------------------..------------------------------------------- DATE_ Alterations and/or recommendations------------------ ---------------- -------------------------------------------•------------------------------------------------------------- -------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------••------------------------- ------------------ ---------•----------------------------- _------------•------------ -------------------------•------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:------_v_, kxtNss^------ -- ----------------- 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 ;0-52 Revised W-2100