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APPLICATION FOR SANITATION PERMIT Permit No. ?-3-0-1- j ( f ,�. . in Duplicate) Date Issued ?77 -77- -- TAplica ion is hereby made to the San Joaquin Local Health District for a permif to construct and installthe work herein described. This application is made in compliance with County Ordinance NO. 549. j JOB ADDRESS AND LOCATI tj--- - --- ------- ------ -------------------------------------------------------- Owner's Name------------------ -- - - --------------------- ---- ------------------- ----- Phone------------------------------------ Address------------------------------- ----AZ------�-------- - - ---- --------------------------1-1------------------------------------ Contractor's Name--------- -------------------- ---------------- ---------------------------- ----------------------- Phone---------------------------------- Installation will serve: ResidencebC Apartment House [] Commercial L] Trailer Court ❑ Motel [] Other F-I Number of living units: __1---- Number of,bedrooms ---/--- Number of baths _-.L- Lot size ho ---------------- ------ Wafer Supply: Public system" -Community system E] Private [] Depth to Water Table -------- ft. I Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam E] Clay Loam"— Clay El Adobe E] Hardpan ❑ , Previous Application Made: Yes E] No 7__1 New Construction: Yes No F-l TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic sewer'is-avaifla6le within 200 feet.) Septic Tank: 't- ' tan c * 'fzortbc Distance from neartst wei��_ " Q-fro No. of compartments------47��O_ --Liqui - ----------Capacity---- Disposal Field: Distance from nearestistance from foundafiop-j-0----V---Di I I , Z e' -- ------ ------ --- ----Size- or pfh___ - �%. -1411- well -_Dist to nearest lof��.]Li�ne__ Number, of lines---- ; Iline__-_---_ *I v- -- ---- -------------- ength of each line--------k,0- �i--- idth of french---- --- - --------- ---- - Tr, 'r Type or filter maferial,:54 7_ Pepth of filter ----.-Total length----.--_-- -4 k- C -60----- ___.:------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---------------- Fl Number of pits----------------------Lining material-- -----------------Size: Diameter------------------!'__Depth------------------------------ - Cesspool: Distance from nearest well-----------------Dista'nce from foundation....--------.-----..Lining material------------------------------------- ❑ Size: Diameter------ ------------------- -----------Depth---------------------------------------------------;Liquid Capacity----•----------------------gals. Privy: Distance from nearest well---------- ----- --------- ----------------------Distance from nearest building-----..-_--------__--_-------.-----_--_-. ❑ uilding------------------------------------------ 171 Distance to nearest lot line---------------------` i Remodeling and/of repairing {clescribe):------------------ ------------- ---------------------------------------------------------------- -------------------------------------------------------- ------------------------------------------------------------------------------------- ----------k__j--------------- -------------------------- --------------------------------------------------------------- --------------------------------------------- ------------------------------------------------------_7--------------------------------- ------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------i--------------------------------------------------------------------------------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 laws, and rules and regulations of the Sari Joaquin Local Health District. (Signedx-XI�__ --- ----------------------------------------------------------------(Owner and/or Contractor) BY:-------•---------------------------------------------------------------------------I------ --------------------------------------(Tif le)--------------------------------- -------------- ---------------- (Plot plan, showing size of lot, location of system in relation Ito we'lls, buildings, etc., can be placed on reverse side). FOR qWARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- ftq BY .------------:�_---------------- ------------ DATE-----Z-77V-1-7 REVIEWEDBY---------------------------------------------------------------------------------------1------------------------------------- DATE BUILDING PERMIT ISSUED------------------------ ----------------------------------------------------------------------------- DATE_ Alterations and/or recommendations:------------------_- ----------------------------------------------------------- ------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- ------------------- ----------------------------------------------------------------------------------------------------I------------------------------------------------------------------ --------------- -------------------------------------- ---------------------------------------------------------------------- --------------------------_-A------------------------------------------- -------------------------------------- ----------------------- -------- -------------------------------------------------------------------------------- --------- ...... ---------------------------------------------------------------------------- ,-------------------------- ------------------- A- FINAL INSPECTION ----- ----------- --- Date---------- �� .•% SAN ate----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreel 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100