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1 APPLICATION FOR SANITATION PERMIT Permit No. ___172_ ___ (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 L CATIO --- ---". --------------------------------------------------------------------------------------------- Owner's Name -- �------------------------------------------------ ------------ ------- ---------------- Phone--------------------------- ---•---- Address------------------.. '��- `" ------ y Contractor's Name------------- - -----'•------- ----------- -.r'1 �,r�C +4 -- --- Phone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1___ Number of bedrooms =, __ Number of baths Lot size Aaxwlr ----------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _" ft Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ San8y Loam ❑ Clay Loam ❑ Clay ❑ Adobe 8"P-ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No [e-,*"`FHA/VA: Yes ❑ No ®,-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) J,Septi "Tank: Distance from nearest well_________________Distance from foundation--- ________._._____-.----____.___-__._-___.__-__.-. 1) No. of compartments ----------------------Size---------------•----------------Liquid depth--------------------------Capacity---------- ------ Dispo al 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 material-------------- ----------Depth of filter material_--------------------Total length___----._____-___________________________ Seepage Pit: Distance to nearest well------- -----------Distance from fou ation___ s nce to nearest lot fine__.4 +_____ Number of pits------f____________Lining material _____-. Size: Diameter_-_ ` ____ srf�_°_____________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 0 Size: Diameter--------------------------------------Depth_------------------------------ ---------------- Liquid Capacity---------•-----------------gals. Privy: Distance from nearest well ____.___-----------------_---------------------Distance from nearest building----------------------------------------- Distance ____ ____.__.____________-______._Distance to nearest lot fine---:- -------------------------- Remodeling and/or repairing (describe):------------------ ay�------ - -._..__c.. -• - -------------------------•--- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawsaann'd ales and regulat' ns of the San Joaquin Local Health District. Si ned1_ ai.�� -------------------[Owner and/or Contractor) 9 ) --- --rflionof -- - -- --- --- By:. f --="-----------------------------•--------------------(Title)------ F--df ---------------------- (Plot plan, showing size of lot, m in relation to wells, buildings, etc., can be placed on reve a side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -----------------------------------------------------------••-- •------------------------ DATE__r--- REVIEWEDBY---------------------------- - -- --- --- -------------------------------------------------------------------------------- DATE- BUILDING PERMIT ISSUED---------••----------------------------------------------------------------------------- ------------- DATE-------ca-------------------------- Alterations and/or re ommendations------- ----------------------------_---- ------------ ---------- ---- - ----------- -------------- -9-------- ..... �_A�Z....... .7--------- cl�z � .Tht---------� -- • ---`----------------------------- -----•----------------------------------------------------------- FINAL INSPECTION BY--------------- - ---------------------- Date---------V� Q N 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. r r�