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APPLICATION POR SANITATION PERMIT Permit No. _/__J03_1/7 (Complete 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 No. 549. JOB ADDRESS AND LOCATION--------- -------- ---------------- ---- - .. Owner's Narne_'--_ x7y"� x~ --------------------------- Phone.y�2.-o _ ------------------------------- - Add ress-___�_ ------•... ---- . ---------------------------------------- ----------•---------------------•-•-------- -----------------Phone._-:----- Contractor's Name - ----------------------------------- � � Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Cher ❑ Number of living units: - ---- Number of bedrooms nh- Number of baths __/--- Lot size --, -x ------------------------ Water Supply: Public system Community system ❑ Private ❑ Depth-to Water Table ft. Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Cla)t Adob(A Hardpan ❑ ' Previous Application Made: Yes ❑ NoX New Construction: Yes ' No ❑ FHA/VA: Yes ❑ Nof' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) I eptic T nk- Distance from nearest well-_______________Distance from foundation-----___---_---__'_.Material----.-----------_-___---__------__--.___---__- R No. of compartments--------------------------Size =` Liquid depth Capacity i isposal Ili d: 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 material--- ------------------Depth of filter material----------- --Total length-.------ _------_-----__---_---_- Seeps e it: Distance to nearest wel ___Distance from f ,,dation Distance to;nearest lot line -- ---- --_- ------Lining material - - ------ - ----Size: DiDepth --------Number of pits----V -- D',, eter__ 3_��_ p , Cesspool: Distance from nearest well-----------------Distance from founc�ation--------------. .Lining material--------------------_------ -- - ❑ Size: Diameter - -- ------Death----------------- -------------------------------I ------------- ------------------------------- ' Liquid Capacity--.:=_ gals. Privy: Distance from nearest Well -.-_,_._--------------------I__-�---_---_-___-D.istance..from_nearest building----- ---._•___-----------_----__-_____-. `j p hJ ElDistance to nearest lot line----------- --------------------- -----------=-----------------------------*------------------------ Remodeling -----------Remode'ng and/or repairin &scribe):- - ------ = = ------- _,V --- -------- ------------ ------- --------• --- ------- t-_.- _ 1 •� e •-------- ----------- :----------- --------------------- -- -------------------------- ----------------------- -- ----------------- ------------------------------- ---------.--------- __ y c y p g pp a �the.:w will be done in accordance with; an Joaquin Count I hereby c if the I have a ared t is a Iicati and a�F ordinances, laws' rul and a ns of f e San o uin L' §d Health Distri "i Si ned g ) --____-- -/ --(Owne or Contractor) " B (Title -- 0 ----------------- (Plot plan, showi size of lot, location of system in relation to wells, buildings, etc.,'can+be p ced on re rse. e). FOR DEPARTMENT USE ONLY .`. APPLICATIONACCEPTED BY--------------------------- --- ----------------------------------------------m- ---- DATE------------------------------------ - -- 1 REVIEWEDBY----------------------------------------------- --- -------------------------------- DATE------------------------------ �, - 1 BUILDING PERMIT ISSUED------------------------- - --------------------------------------------- ------- +DATE----------------- ,! ----- -- ----- --------------------- Alterations and/or recommendations:------- ---------------------------------------------------- ----.:-.---•---•------------F ------------------------- -----•-------- -- - ------- -- ------------ -------=------------ ----------------------------------------------------------------------- f t --- --------------------- ---------------------- -- --- ---------------------------------------- -------------- ---------------------- sA-.-� .--<c. ---_--_ •-_-----_-----_--.--- � • ' � � .� t FINAL 10E SAN BY:.--------------------- ------------------------------- --- ? Date--r'----- ---------- ----------------------' e 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, California Tracy, California -A ES-7-2M Revised 1.57 F.P.CO.