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APPLICATION FOR SANITATION PERMIT Permit No. . 1.-0 3 (Co;hplete-in-Duplicate) 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 N-075 49 `. . � ------------ --- ------------------------------ ..... --------------- JOB ADDRESS AND LOCATIO/N-------- -- •- �7 ----- ' -7 -� G f � .�!�. %�_ !� --- ----------------------------------- --------- ----------- -- Phone_. Owners Named.,---- W_ a � ��y f -r' ___-� ------------ r.v ---- -- Address= __._. .---------------- nE Contractor's Name------------- Installation will serve: Residence �� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [I Other ❑ o�__. Number of baths z ---------------------- e 73 ,�C --- Number of living units: �____ Number of bedrooms . Lot size ______ _ �._ Water Supply: Public system El system'❑ Private Depth to Water Tablets f+. t Character of soil to a depth of 3 feet: Sand ❑ Gravel L] Sandy Loam ❑ Clay Loam ❑ Clay [I AdobeA Hardpan ❑ I ! Previous Application Made: Yes ❑ No 2 New Construction: Yes ❑ NFHA/VA: Yes ❑� No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Se tic i nk- Distance from nearest well_______.__-_LDistance-from-foundation:_--n--.-.Material -------- Size--------------------------------Li uid depth--------------------------Capacity f1 ti No. of compartments----------------- - - q isposal Feld: Distance from nearest well__`? - _.._.Distance from foundation,__-�- - Distance to nearest lot line----- _.___ --- �/ Number of lines------- ________-s__.____r_--Length of each line------- -----------Width of trench .1--------------------•--- Type f f lte�matenaL� y" ept�h`of,,filfer material-- `- ---------Total 4ength----a-`'-------•--------------•------ f• -�' - D Seepage Pit: Distance to nearest well_______,_: _-______ Distancefrom. foundation___________________:Distance to nearest lot line_______._________ ❑ Numbbr of pits"_.__}--------------Lining material-_----------�-Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance frdm#Re"arest well___=___.________Distance from foundation___________________Lining material__--_____.___.___---_____--______--__ Size: Diameter Depth----------------------------- ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_._.__---.1------- - Distance from nearest building------------------------------------------ �k I ❑ Distance to nearest lot kne------------------ --------------- ------------------------:--------------_ Remodeling and/or repai�irsg'(describe}:__="`•__"""•""'-"""'----------- -----------------------------------I------•------------------- ----- --•--------•---- -------- ----------------------------------------------- ' -------------------------------------------••--------------------------------- ____________________________________________ ------------------•------ ------------------ prepared pp Health District. `J _ ------------------------------ ------- -- ---"•tions of +he_San Joa wn Laca1--------.----•--------------------------_---------------------------;--- --1----------------- r - --- fi s ar have regulations 9 +: in County } 1 hereby certify that I have re ared +his application and that the work will-be done m-accordance with San .Ioa u ordinances, St a {a ` y r c ` # wner and or Contractor) t.� . -: ------------------------------------- (0• (Signed) -" .# r ----------------- --------------------- ---------------------------- - -� 1u_ -> ---- (Plot = -------------------------------- By: (Plot plan, showing size of lot, location of system in r Jlation to wells, buildings, a+c., can be placed on reverse side). n ' FOR DEPARTMENT USE ONLY -------------------------------------------------- APPLICATION.ACCEPTED BY---------------- ----- ---- DATE REVIEWEDBY - ----•- -------------------------------- ----------- BUILDING PERMIT ISSUED--------------------------------- C-•---------- - -------------------- DATE ----------------------------------------- I. Alterations and/or recomm nda+ions:----------- -- ------------------------------------------------ I ----------- {�- 2 : 7 o,W --- �`° `---- -----------------------------------------------------------11 ------------------------ �� ---- ---- ------------------------------------------- -----_- ----- ---------------------- -------------- ----------------------•------------ Date FINAL INSPECTION BY-------o-=-- -- ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y. ES-9-2M Revisea 1.57 F.P.CO.