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FOR FFICE SE: --------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...x. .7.3__ --------------------------- ------------------ ---------- (Complete in Duplicate) �l ` --------------- --- This Per Expires 1 Year From Date Issued Date Issued 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. 54 . nn JOB ADDRESS AND LOCATION...- OCATION... A-1 4--71- ---- ------------------------------------------------------------------------------•-------------.... Owner's Name `-------------- --------------------------------------------- ---------------- Phone------------------------------------ Address............../11/11/1 _ - - Contractor's Name------------ - - - -----_._ �----`- ------------------•--- Phone----------------------------------- Installation will serve: Residence 2---'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of,bedrooms S.- Number of baths /... Lotsize`._�� -- - - ----- ------------------------------- s Water Supply: Public system ❑ Community system P--private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe; Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ + New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f ____Distance from foundation'---/ Septic Tank: Distance from nearest well_____________ ::----.Ivletel_, F _ No. of compartments __- ------------ Size_ �"�__ F p -*- - - --- � ,�-"��---�-Liquid depth--`-_'/_�'_-_,�`-------=-- Capacity--= -�Q---=-- Disposal Id: Distance from nearest well,_;__-__ -_.__:.Distance from foundation--/If-----------Distance to nearest lot line__ .. ..t . , - �oe 01 Number of lines---------�___-,`-`- Length'of each line------Pt __- Width of trench._.--------------------------- Type ----------------------- l De th offilter material_;_, _ - -----Total length_._.- - -----------------_ Q:I Type of filter material_/-_r__ p /, Seepage it: humabee of pits to rest welk----=-------------------- from foundation--------_-----------Distance to nearest lot line______--_________ 3 19 aterial ={ = -- : Size: Diameter Depth Cesspool: Distance from nearest well_________________'Distance from foundation--------------------Lining material------------.-__-__-__________-______- ❑ Size: Diameter:------------------ ------=------- =-Dept h--- -------------------- •-----------Liquid Capacity---------------------------gals. Privy: Distance from nearest well----------------------------------________________Distance from nearest building__-.------________________________.-____. ❑ Distance to nearest Iot'line.- -----------------------------------------=-------------- Remodeling and/or i �lLw_-_` t'1 -----•----------- repairing (describeJ________________ ./ •------------••--------------------------------- ------------•--•----------------•--- ------ in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin-Local Health District. (Signed)------- •--•----------- - = or Contractor] k By: - -----------------------------(rile) c - �1 (Plot plan, showing size of lot,-Iocation of syst n relafiion to wells buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY------- -=-'-------- J v — -"----- --:-----------•---- DATE-------ff-�_---�-` 6 REVIEWEDBY ----------- ---- ------- ---=------------------------------------------------------------ DATE-------•------ j BUILDING PERMIT ISSUED' - ---------------------------------------------------------------------- DATE------ -•--------------- Alterations and/or recommendafions:-----+ - ----'------------ -----------------------------------------------------------------_----------•------ --•--------------------------- --------------- ----------------------------------------------- __________ _______ _ -----------------F _____________ --_.__. c _ 1 ��- _._.� ------------ --- � -------------- ---------- - ------------- ------ -- - ------------------------•----------- ------------------------------ ------------------- ----------- ------ --- l FINAL INSP0-_ 0------ ------- - Date --------- ' SAN JOAQUIN LOCAL HEALTH DISTRICT f 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9-9 REV19 E0 n•y9 F.p.0 D.ZM 6-6p