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� r APPLICATION FOR SANITATION PERMIT Permit No.__1�------ (Complete in Duplicate) Date Issued __f-1-7 -S3 ' 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 No. f5J49. ,,. JOB ADDRESS AND LOCATION--------------------------- #A=1- ` �/�f�W-• Owner's Name---------------- --------- Yfj1/ �1_aP - - ------ Phone---- ---------------------------- Address. Contractor's Name---------------------------------------------------------------------------------=--------------------------------------------------=---------- Phone----•------------------------------ Installation will serve:,e,Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑' Motel ❑ Other ❑ Number of living units: --------- Number of bedrooms _____I__ Number of baths -------- Lot size ----------- _�__�--/Ol.-_'___________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ________ ft. i I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ I Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: s (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--- Material El _ Ca ( No. of compartments--------------------------Size----------------- -- depth---------------------------Capacity ________________ Disposal Field: Distance from nearest well_________________Distance from foundation,-------------------Distance to nearest lot line-____---___.____- ❑ Number o-i lines-----------------------------------Length of each line-----------------------------.Width of french.---------------------------------- Q Type of filter material-------------------------Depth of filter material-----------------------Total length-------:----------------------------------- -- Seepage Pit: Distance to nearest well ______---------------Distance from foundation------------------- Distance to nearest lot I;ne----------------- El Number of pits---------------------Lining material-----------------------Size: Diameter-_-- -----Depth----- --------------------------- Cesspool: DJ stance from nearest well-________________Distance from foundation------------------ Lining material------------------------------....... ❑ Size: Diameter-------------------------- -----------De Depth---, Liquid Capacity------------- -------------gals. ] Privy: Distance from nearest well--,;:- --------------- ,� ..___Ir!!1Disfance from.nearesf building Sb/--------------------- Distance to nearest lot line_____________________ # ;yam Remodeling and/or repairing [describe]---------------•-----------------------------------------•----------------•----------------- ------------------ ----------------------------------•--•---••--------------------------------- -� rrr, ,r�, • �5------ Pfd _4�.�9� 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 law and rules and regulations of the San Joaquin Local Health District. (Signed) --- -- �`''- ---- �� (Owner and/or Contractor] By:--------••---------------------------------------------------------------------------- ----(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------------ REVIEWED BY DATE BUILDING PERMIT ISSUED---------------------------------------------------------------------------- ------------------------- DATE Alterations and/or recommendations:------.--------- -------------- -------------------•--------------------------------------------- ------------------------- ----------�- -�14----------- �t� -------C K— p--- ----'----------------------------------------------------------------------------•--------------------------._.. ---------------------------------------------------- ------- ------ -------------------------------------=--------------------------------------------------------------• ---------------------- --------------------------------------------- -----------------------•- ----------------- -------------------------- ------------------------------------ . • -- FINAL INSPECTION BY:--------- Date.-- ... ------------- ------------------------------------------- SAN - ---- `S ------------------------------------ SAN JOAQUIN SLOCAL 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 . 1 ES-9-2M 10-52 Revised W-2100