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APPLICATION FOR SANITATION PERMIT Permit No. ____11F-7-,7_ (Complete in Duplicate) Date Issued ___/1--.__ 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 fCounty Ordinance No.._54"-- JOB ADDRESS ANQ L CATION__...' Owners Name --1/,k-a;,�1-•-=---------------------------------------- Plione. Address------------------------------------------ -'-- � - • - - -----------+-----l--�f---------------- ---- ��'--�=------....------------------------------•--•--•-------------- Contractor's Name ------------------------------------- --------- — ----------------- ------------------------ Phone ---------------------- ------------ Installation will serve: Residence aa,' Apartment House ❑ d6mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ - .— i Number of living units: l_____ Number of bedrooms .5___ Number of baths__-____ Lot size13-341 ------------ Water Supply: Public system ❑ Community syste .-❑ Private Rj"`Depfh to Water Table 2 .� ft: Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Z] Clay Loam E]Clay ❑ Adobe ❑ Hardpan E] Previous Application Made: Yes ❑ No New Construction: Yes Flo ❑ FHA/VA: Yes Rj No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:: ; (No septic tank or` cesspool permitted if public sewer is available wifhin 200 feet.) / Se tic nk: Distance from nearest well_4!.p ..... . Distanrce fro foun a •on-.-_� U_________-Maferial_i_____=C -- ...... No. of compartments ...... --------------------5ize-/---=--=---r.---------liquid depth------------Capacity--I--•-------------- Dispo^s�Field: Distance from nearest well_.: ------- Distance from foundatio .,� _ __ Distance to nearest lat ine______________ LoC ®y � r D- :r-, •t-,--''rr i Nurri6er of lines______,-. � r__ Length of each line___7�x.Width of french__- _`_�_-.__________.____ Type of filter material::-_;'L.�-!dlss Depth of filter material__ -__O �__ Total length____/___,_j+_________________________ Seepage Pit: Distance to•nearest well___ _________________Distancetfrom fo_undation-------------------- Distance to nearest lot I;ne ----------------- ❑ Number of pits ------i --------------- Lining material ---I----------_ ------Size Diameter. --------------------.Depth- _-.._----------------------- IF Cesspool: Distance from nearest well_________________ Distance; from -foundation�__.!_*____- , -__._-__Lining material __.-____._.___.____.______._________ ❑ S'ze: Diameter-------------------------------------Depth#----------------------------------'`'-: --- Liquid Capacity ---------------------------- gals. Privy: Distance from nearest well ___---------- _------------------ _--------- .----- Distance from nearest building ------------------------------------------ ❑ -Distance to nearest lot -lire ----------------------- - } t .. Remodeling and/or repairing (describe); --------------------------------------------------------------- ::-------------------- --------....---------- -------------------------------- •---------- --------------------------------------------------------- -----------------------------------------------•-- ""------------------------------------------------------- -----------------------•---------- ] ---------------•----••---------------------------•--•--------- --------------------------------------------------------=-------------------------------------•----------.----------------------------------------------------------•---------------------------------------------------- I hereby certify that I have prepared this a plication and that the work will be done inn accordance with San Joaquin County ordinances, State laws, a ales a d regulat" of the San Joaquin Local Health District. t i _ ---- ------- Ow (Signed]_______________ { (Owner an or ontractor -------- By: ------------------------------------------------:---------------------------=---------------- t-----(Title}---------I------------------------------------------------- y (Piot plan, showing size of lot, location of system in relation to wells, buildin s, etc:, can be,.placed on reverse side). _.FOR"EPARTMENT �J,SE ONLY i - APPLICATION ACCEPTED BY____ -4—z'1� ' ��-------- DA d ------------------------- REVIEWEDBY --------------------------------------------- ------------------------------------------------------ -----:------------------------------------- f� DATE---- ---------------•-------------•---•------------------- BUILDINGPERMIT ISSUED ------------------- :------------------------------------------ --------------------------------------- DATE ------------------------------------------------------------- Aiterafionsand/or recommendations:--------------------------------------------------------- -•---------------------------------- .------------ ------------------------------------------- -------- ------------------•--------------------------------------•---=----------------------------------------------------------------------------------------------------------------• ---•-----•------------------------------ --------••--------------•----I--------------------------------------------- -----------•----------------------------------------• -------- 47 .. ---------------------- - __. FINAL INSPECTION BY:.----= --- - ------------------------------------ Date = - ---- ------- ---•----------------- 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 ES -9-2M , Revised 1.57 F.P.CO. 7a