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1. APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 11/ Date Issued __-_f--3/---- Application is hereby made to the San Joaquin Local Health District for a permit construct and install the work herein described. This application is made in compliance with County Ordinance No 104 TION l.�.-JOB ADDRESS AND O Owner's Name--------------- NAY!---- _M e f"- - -----------------------------------------------s- --------R-------!--'----- Phone+ --'-r- -------------------------------- Address---•----------------------------------------------------------------- ---- --------------------------------------------------- �/ Contractor's Name ----s-------------- '- � c----------1_�_ 9-------------------------------- ----------------- Phon--�k-?Owi Installation will server Residence I Apartment House Commercial Trailer Court otel ❑ Other ❑ Number of livingunits: -1 y ___,_ Number of bedrooms__--_ Number of baths _1____ Lot size l00*10�________________________________ Water Supply: I . Public system Community system E]Private ❑ Depth to. Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe IN Hardpan ❑ Previous Application Made: Yes ] No Dd New Construction: Yes ❑ No FHA/VA: Yes ❑ NoX. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or' cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from' nearest well ----------------- Distance from foundation ------------------- Material -------------------------------------------------- ❑ tlS 1 No. of compartments ----------_------------- Size ----------------------------:--- Liquid depth --------------------- ---- Capacity ----------------------- Disposal Field: Distance from }nearest well --------------- :_.Distance from foundation -------------------- Distance to nearest lot line _______---_-_____ ❑ Number of lines----------------------------------- Length of each line -----------------------------.Width of trench ----_--------------------.--------- Type of filter.materia------------------------- of filter material_______________________Total length -------- ------------_______-___f.__ Seepage Pit: Distance to ne rest well__*qj0HR0__Distance rom ndation_;rZ_�f�__Distance to nearest lot line ----- t_S_____ Number of pits_ --------- Lining material__�___Size: Diametc�____A/R�.___.Depth__aZ47_-__________________ ,i Cesspool: Distance from nearest well __.__________.__Distance from foundation __.____._._..__..Lining material _------- _________________________:_. ❑ Size: Diameter------------------------ ------ ----- Depth ------ ---------------------- ----------------------Liquid Capacity --------: -------------------gals. Privy: Distance frominearest well ---- ___-___________r______________._._--_-_____Distance from nearest building ______.________________________.__._._- ❑ Distance to nearest lot line----------------------------------------------•----------------------•---------------------------------------- ---------------------- Remodeling and repairing (de; ribe}: I -_.. -- ------ - ----------- I 7 ------------------------------------------------------------------------------- -------------- • - - ------------------ ---------------------------------------------------------= ----------------------------------------------------------------------------- - ------------------------- ------------------------------- I hereby certify that I have this app I* 'on and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules n ulatiogs of ,fe San Joaquin Local Health District. (Signed) --------------------------- ------------ --- ----�flk- -- r ----------- , ---=---------------------------------- -{ wner and/or Contractor) f - -- - -- r Title BY= = dr { } t - = s (Plot plan, showing size of lot, location of system in relation to wells, uildings, etc., can be placecUn reverse side). FOR DEPARTMENT USE ONLY I_ BUILDING PERMIT ISSUED ------------------------------------------------------------------------- DATE--------------- APPLICATIONACCEPTED Y.___ ------------------ -- -------- REVIEWED BY------------------------• ---- �_.-- ----- -- - ----- ------ - --- - ----- --------- DATE--•-------�-,- UILD G P S ------------------------------ DATE ------------------ Alterationsand/or recommendations:---------------------------------------------------------------------------------------------------------------------------------------•---------------------- # .. ---------- --------------------------------------------------------------- -- ------ •---------------------------•------------------------------._....------- -------------------------------------------------------•----------------------------------------------------------------------------------------------------------------- -------------------------- I FINAL INSPECTION BY: -------% ---------------------------------- Dater SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California i Lodi, California Manteca, California Tracy, California ES -9-2M , Revised 1.57 F.P.CO.