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APPLICATION F SANITATION Rlv(1T 1� Permit No �___7_2__._I_-__. r ' Com ete�in Du licate�� i S R �- P Date Issued Application is hereby made, the San Joaquin Local Health District for-a permit to construct and install the work herein described. This application is made in compliarice with County Ordinance No. 549 ` 67- JOB ADDRESS AND LOC�AT ON _� .#^ --------- ------- -- ------------------------- = �- --- , --- - „--------------� l 3 Owner s Name------ "-- ' - -- . Phone-------------------------- ------•--- w �T Addressw R`�`'"':.Ur4 1 r ---------------------------------------- ------- Contractor's Name ----------------------------------- •------------- Phone----------------------:----•------- Installation will serve: Residence &roetpartment House- Coriimerci ❑ Trai er urt ❑ Motej ❑ Other❑ I Number of living units: �___ u, bar of bedrooms Number of baths ° __ Lo size'____-- ________________________________ _____ Water Supply: Public sys+em- Community system ❑" Private.❑ epth to'Water Table __--____ ft. - Character of soil to a dep+h"of 3 feet: Sand ❑ Gravei 0. Sandy Loalm' Clay Loa ❑ Clay ❑ Adobe�ardpan ❑ Previous Application Made:',Yes ❑ No [ New Construction: Yes �No []: FHA A: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: > • Y. (No septic tank er'c Wsspool pert itted if publics wer is available within 200 feet.) Sepfic nk: Distance from nearest well ------------Distance fr40f oug jation_ __ ____----------Materiel_r-____-------------------- ----------- _____-____-__-_____ No. of compartments_____-__----- ------ .. .iz ______Liquiddepth ______- - Capacity___ F-__, Disposal Field:. Distance from"nearest wel __ _ ____________Distance fr-m f" clptio ___�_ Distance to nearest lot line_ ? ' �!A T - _ , ' '___TLS G , - umber. of.lines----------- --- -- ----------- engt of e� l�ney-- �' �Niath of trencn ---- '• - Type of:filter materi . _ epth of?�Iter material_:-----46 f ____Total length___ __I__ --- ______ Seepage Pit Distaricel'to nearest well _ ' :Distance from faundation ..Distance to rest-lot line_________________ ❑ Number`of pits. -._--- -- ----Lining me,terial------- -----j-----Size Diameter' --------------------Depth--- ------- . _--------- ---- I" .-T. .-, r � Cesspool: Distance from nearest well a �"D'istance from foundation_____ -- .,Lining material------- ----------- ❑ Size: Diameter__ :__ -,�_:'fDepth-----------= -�----------------------------- -- ---- -------Liquid Capacity-- -� ---------_--__--_---gals. Privy: Distance from nea est well_-_ __________ ____ _-°_._Distance from nearest building-: __--__ _----------------------------- Distance to nearest-lot-line--"~^"'~----"'__�'----------------- =" = = utRemodeling and/or repairing {describe):"_' s `----- ---- ------------- -j----------._.._... I a Y ------------ -------- ------ -------- ------------------------------------------ ' ---_ ----------------- ------------------ --- ------------------------------------------ -------- --------- --------------------- ----- --p PP = -- - ar-----I e�, Y e laws, and` ules and regulations li the San Joaquin - will-------------------------------------------- -- -- Sa -- qui - - I hereb c rtif that I have� re aced this a licatian and that the work will be done in accordance with Sa�Joaquin County Local Health District. (Signed)...___ (Owner and/or Contractor( IBy----------- -------r---------••--------------------------------------=-•-'--•-------------------------_--_--=-•--------------.(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-- --------- ------------------------------------- ----------------------------------------------DATA-_.__. . REVIEWED BY-------`--------- --- ---------- ------------------------------------,-------- ---------------------------------- DATE__ -------------------- -------------------------------- - ------- ------ `--•------- ' BUILDING PERMIT ISSUED---------------- - - --------------------- -----------------------------I -------------------- -=- -------------------------=-------- DATE__--- ----------- ----------- Alterations and/or_recomme dations----=----=--------- --------------------- -------------------------------------------•---------•-•----_ = - = ----------------------------------------- --------------------- : . --------------------------------------------_--------------------------.__Y---------- ----- -------------------------------------- -___ _ ____-__-__--______}-----_-------------�1_-_ __________ _-_______---_-. _----.--- W J- _ ._. FINAL INSPECTION BY: -" '�-=-J- --�`----•- �-��=.--�- �..,..� ,w.. �.. Date-----------=--=- ------------------- - ---------------------------- IN --------------- --•-- SAN JOAQUIN LO�AL 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-4-2M , Revised 1.57 F,P,CO.