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i FOR OFFICE USE: - - -------- - ----------------III --`-'-. _._._______________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. 1.7.77.1_-__ 7-- {Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued .x_1110_ i � Application is her 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 AN LOCATION------- ___. Owner's Name"` -{--•-•--- '---- one---- Ph .•------------------- ---•-------- Address----------t-5--,;�Ji_:.. ----- ---- t ---------------------------------------------- Contractor's Name----- - •-- --- t •--------------- Phone----------------------------------- Installation will serve: Residence 2j Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.___!___ Num ber�otbedrooms _.3__ Number of baths __I____ Lot size .J..O x �� -----------7---------- Water Supply: Public,,system ❑ Community system ❑ 'Private Depth to Water Table -Z-Off. Character of soil to a depth of 3 feet. Sand 0 Gravel ❑ Sandy Loam [❑. Clay Loam ❑ ClayE] Adobe [rnfardpan ❑ Previous Application Made: (If yes,date____________________) No .ff� New Construction: Yes gr"'No ❑ FHA/VA: Yes ❑ No [fir TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) • � No. of compartments--------------------------Size---------------•=-----------_---Li u---------- -- -:Material----------- ------------------=---------------� Se c an Distance from nearest well________________ Distance from foundation--------------- depth__._._.____________-....__Ca Capacity---------______._____. I P Y 4 -------- t Disposa Field: Distance from nearest well.(__----Distance from foundation___4Q-_ _____.Distance to nearest lot line_______._. Number of iines_1.......1.......................... g i------ `' Len th of each fine----7-D------------ Width of trench_ - ----------------------- a Type.of filter meteria-l__ "m--Ef ------Depth of..filter.material_-hr."_____ _"--.Total length-------7A--'_______-_______________ r Seepage Pit: Distance to nearest well-_----------_----------Distance frons, foundation--------------------Distance to nearest lot line-_.__.____-_____ ❑ Wmber of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------•-------------- ~J rl Cesspool: Distance from nearest well ______________? Distance from foundation--------------------Lining material __.__________--.-.-___.______-____ G ❑ Size: Diameter---------------------------------- Depth----•----------- I--------------------.--------J-----Liquid Capacity--- ------------------------gals. Privy: Di`stance from nearest well.__________________________________"...........Distance.from nearest builcling------------------------------------------ 1 F El Distance to nearest lot line-------------- ------------ -------------- -----------------------•-------------------------------- - Remodeling and/or repairing (describe):---- `rl p�?.•gyrt�a� ._ `_ ------•---------••------- ------------------•----------------_--------=------------------------------------- r--•---.__-•-- --------------------------- -------- -------- ------------------------- ---------------- ---------------------------------------- ,, ------------------------7--•---------...---------•------------------...-----------------•-------•-----------•-------------------------- ----------------------------------------.------- --- - - "----------------- ---------------------------•-----•-------------'----------------------------------------------`------- - - ------------------------------------------------------------ I hereby certify that I have prepared this epplica+ion-and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)- ------------------------------------------------(Qwnef, d�or Contractor) By:------ - -------------------- ------------- ------------------------ ------------(Title)-------------------------------------- I (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 Ji APPLICATION' ACCEPTED BY--------- • - ---- ---------------- ---------------------------------------- DATE__.__lP-//_ = - - ------------------- REVIEWED BY - ---------------------------------------------- -----------------.DATE------------ BUILDING PERMIT ISSUED '--------------------------- --'- ---- ---"------ ----••------ -_-------------- . Alterations and/or recommendations:. '---,-------------- ------ ----•--- - i -.. ------------------- -------- ---------'---- ---------- ----- -------------- ---- - -------------------------------- - FINAL INSPECTION BY:. _ � t- t Date--- r --? 6 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 911h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVFSEG 8-59 3M 3-'63 F.P.CC. er