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APPLICATION FOR SANITATION PERMIT Permit No. .......... .....' (Complete in Duplicate) Date issued _17-71 "-127-'� i Application is he 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. 549. - / �" s `5 ------------ JOB ADDRESS AND LOCATION------- ---------- C ' 1 3 n1,--------- 4t5 � - Owner's Name. r� S� � ._ -- - -- - - -- Phone _ - `---- 7` f` --- Address--------------------•"` ---------- Contractor's __--- _ -T - r Contractor's Name-A --------- - ay Phone---------------------- Installation will server Residence DA Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel tj Other ❑ Number of living units: __2^_ Number of bedrooms -_--L Number of ba#hs / .__ Lot size _____-__._.___�_.X��_----_--._--------------_ 1 ft. Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- Character of soil to aldepth of 3 feet: JSa d ❑"Gravel [I Sandy Loam E] Clay Loam ❑ Clay [-] adobe I�' Hardpan E] Previous Application Made: Yes E] N:o New construction: Yes E] No TYPE OF INSTALLATION AND SPE IONS: r (No septic fan or cesspool permitted if.p�iSblic sewer is available within 200 feet.) Septic Tank: Distance from nearest welkA_. - ��_.-_---___Distance from foundation- ----------------------- ------------------.Material------.-_,___--...------. . is'(<N No. of corrpartme ts------------ ` == Size ---------------------------Liquid depth-------------------------Capacity-- ---------- 7 1 s I Disposal Field: Distance from nearest we"I------— from foundation___�d-r..........Distance to nearest lotline----------------- Number oii lines___ ____ . _ - -.='.L)ength df(each line__-----.------ Width of trench.- '-�ry----------- T , e of filter material___.-_ ____ depfli offlter material-------es .__ -----Total length-------------- �-.------------------ �-- Seepage Pit: Distance to nearest well--- -__---- __-.-_-DistancOfn�orm foundation------.-------------Distance to nearest lot line_-.-_.._--__...- ❑ Number ofpits- Lining material--------0-- ---------.Size: Diame#er--- -------------------Depth - Cesspool: Distance from nearest well-_�------.Distance from foundation--------------------Lining material---_-.-._.------____--.----.--_--- ❑ Sizer Diameter--------_----------------- ------- �Depth------------------------------ --------------------Liquid Capacity----------------------------gals. Privy: Distance fro m—nearest-welLr -------------------------______....Distance from nearest building-------.---------------------------------- -- Disfonce to nearest lot line---------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (dscribe) a- ----------------------•--- ----------------------------------------------------- ----------------------------------------------------- •---------------------------------------------`---•------------- ----------------- -------------------------------------------- ! herebcertify that'I haveprepare d-this application and that the work will be done in accordance with.San Joaquin County ordinances, State aws, and rules nd reg_ulaions of ti5an Joaquin Local Health District. 1 {Owner and/or Contractor) (Signed)--- •----------- --••- -- --•----!-- �-=--_--•' _----- ---'----- ---- ------------ ------------------ ----------------- ---------------- BY: `--------------[ . ; �:{ ----------- ------- --- By: -- (Title) ~�--�./ (Plot plan, showing size of lot, location of system-1m�elation to wells, buildings, etc., can be placed on reverse side). F*OR DEPARTMENT USE ONLY < . x APPLICATION ACCEPTED]BY a `--------- -------------------- --'----- -----------DATE--__. REVIEWEDBY `.. '. --------- -------- DATE----I----------l---�----•--------------------------- BUILDING PERMIT ISSUED----------- ------------------------------------ 4 v ,.. r.. - -- ---- -- DATE----- ---------- ------------- -------------•----- Alterations and/or recommendations:----------------------------- •------------- -------�--- .. =-- - -----------------------------••- ------------------------------------- ------------------------------------------------------------------------------------ ---------- ..... f ------------ -6-------------------------------------------------------------- FINALINSPECTION BY---------------------- ------------------------------- --------- 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, Califorfnia Tracy, California ES-9---2M 1052 Revised W-2100