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APPLICATION FOR SANITATION PERMIT Permit No. _117k__-- t (Complete in Duplicate) This Permit Expires 1 Year4rom Date Issued Date Issued Application is hereby made to the San Joaquin Local Heal+h District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION- .� c?.N..._Jcr c.;T(f ! Q�f f} �---_ --. - t } ------ -------------- II Owner's Name `---- -------------- 1 X-_... ---------------- Phone--- v---------------------- Address -------�---`•- Address-------------------------- -----• • ----------- -------•---- ------------------------------------------- Contractor's --'�--` -------:""-``---- Contractor's Name - } -------------------------- ---- Phone----------------------------------- Installation p Installation will serve: Residence i9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __/___ Number of bedrooms __4 NumbL of baths__ Lot size ___-_ .X-1_a Q_--_____-__-___________ Water Supply: Public system U& 'Community system ❑ Private li Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy`s oam ❑ Clay Loam F] Clay ❑ Adobe k. Hardpan ❑ Previous Application Made: Yes ❑ No 5j, New Construction: Yes,®' No ❑ FHA/VA: Yes 5� Nom- TYPE OF INSTALLATION AND SPECIFICATIONS: I - a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r I �,� � � � Septic Tank: Distance from nearest well___'r"__----Distance from m foundation____ ___--Material--- 9�' - ----------------------------- Disposal Field: Distance from nearest well fro�x � Liquid depth_-.____�_____-__.-Capacity___��_--_-- Dis No. of compartments________ --______.-___Size___��x__ p rin foundation____Z4_______-Distance to nearest lot line___..... Number of lines______________`,�.-.�__..___Length of each line_________�_________-.Width of trench---------?-_y-__;___--_-__-.- . # V1! Type of filter material__ _ Depth of fil}er material_________ Total length_______________--------------------------- Seepage ___________�-_�___-_ Number of its______________________Linin material_________! p❑g Distance to well___________________Distance fro'' foundation--------------------Distance to nearest lot line_________-___-__ O ee a e it �,-------- Size: 1Diameter ---------------------Deptn--------------------------------- Cesspool: ------------------------ --- esspoo : DDiameter nearest well- ------------- Dpthce n foundation------------------- Lining material------------------ ---------------. "r1 ❑ Size: Daeter. --- ----y - -- - e -- ------------------------------------------Liquid Capacity----------------------------gals. CA Y� _ _ _ Priv Distance from nearest well____________________________________ __ _________Distance from nearest building__----------_--____________________ ._ . � ❑ Distance to nearest lot line 0--------------------------------------------------------- ------------------------------ Remodeling and/or repa€ring (describe)_____________ ---•--------------••------------------------------•---------- I. - ------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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. (Sined fi------------------------------------------------------------ 9 )------------' �-- ----------�----- /.a`--- --------------- -- -� (Owner and/or Contractor) BYE �------ ------------ C�i�---t��-------------- ------- -----------(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 -------------------------------------------- DATE_ REVIEWEDBY_ - - - ---------------•------------------------ €Y-- ----------------------------• DATE-------- ------ BUILDING PERMIT ISSUED---------------------- ----------- ---------------------------------- '------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations: 1------------------------------------------------------------------------------------------------------- i ---- --- C---- ---- _ ----- rl ----------•------ ------- ------- ..... � l .. rIII ��--------- -- --- ------------ --- -- -r - ------- ----- --- - ------- ------ ' FINAL INSPECTION BY7.— _ :.---- - x � Date----- --------- ---------------------- SAN --- ---------------SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American 5treet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California k Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P.Co. 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