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FOR OFFI 5 � - �� •" _ 57S _F-s_�_T :3 �_��. '� APPLICATION FOR SANITATION PERMIT Permit No. ..� _ -1---! ---------------- (Complete in Duplicate) --------------------- Date Issued .-_._. This Permit Expires 1 Year From Date Issued Applicatiori,.is hereby made to the:ISan 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 ADDRESSrAND LOCATION -----1 6-2,6- � ' �/ Owner's Name \'/ -_./. Phone = "`"' Address '� ...-- ----,'-- - ---------------------••---- = Contractor's Name-----x -- --- --- "'------ ------- Installation r te- _'.. ±Phone--------------- Motel Other will serve: Residence ❑ Apartment House [�Commercral ❑ Trailer Court ❑ ❑ ❑ Number of living units: ° ry, Number of bedrooms __' Number of baths _ _ Lot size _._. -. ---------. -. Water Supply: Public system ❑ Community system ❑ Private .J�<- Depth to Water Table _ t.� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [j. .Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (if yes,date-_-----------------) No [ New Construction:- Yes Rio ❑ UHA/VA: Yes:Zf ,No ❑� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool'permi++ed if public sewer is available within 200 feet.) .Septicnearesf well---- __Distanceif om fou dation_--A---------Material---�/-C.�'_ l _� ' -____. -• [ /' No. of compartments-----�______________Size__ ___;,,l _--Liquid depth__--- ,/: .__Capacity.. _.._. Tank: Distance rom" Dis osal Field: Distance from ,per i i ! p nearest well. _-._.Distance from faundati n__ __.__.___Distance to nearest of line___ -_ --- -- -Len th of each line-_-- -/-�- - ---------------Width of trench---�---------------------- ----- if Number of lines______A_.�_ gGr T e of filter material- 0--Depth of filter material---- `f------Total length____ _______________________ i t / i € / Seepage Pit: Distance to nearest well--_ _. __Distance from foundation_._. __ ------- -, p g __.___.Distance t neprest lot line_ t Number of pit's--.-r�-------_--Lining material-.- - foundation i : Diameter. /�-�ateDrial------------------------------------- Liquid th_ � { 4 Cesspool: Distance from nearest well-----------------Distanceg s . Size: Diameter---------------------------- Depth Li uid Ca°acit -------- als. ❑ -------- --------------------- ---------------------- q P Y 9 Privy: Distance from nearest well_____-__________________\-_-____-.___.-......Distance from nearest buildigg______.________-----.-_-__._-_-_.____-.-_. ❑ Distance to nearest lot line------ ----------------------- ----- ------------------------ -----------------:�---------------------- --------------------------- . . ------ ca'------•-------------------------------------------------------- Remodeling and/or repairing (des cribe}:_�-- ._� - ---- --•-------------•---•--•--------------------------------------------------------------------------------------•---------------------- - ------------- t t � ordinances, Sate laws, and rules u ----------- ---------- ----------- ------- ------- I hereb certif that I have Irepared this application and that the work will be done in accordance with San Joaquin County and regulations of the San Joaquin Local Health District. � Co(St (Signed ntractor) ---- - ----------- ------ ---------------------- --------- - /l --------------- (Plot plan, showing size of lot, location of system ' ation to wells, buildings, etc., can be placed on reverse side). j FOR DEPARTMENT USE ONL APPLICATION ACCEPTED BY-_-------------------------- -------------------------I--------- DATE--------- ------=------------------- -- l , REVIEWEDBY-------- j---------- --------------- --------- ---- -------------- DATE BUILDINGPERMIT ISSUED----------'------- -----------------------------------------------=--------------------._ DATE------------------------------------------------------ t Alterations an /or recommendations: �"'` ,tee r i—--— cry----��- -------------------------------- -------------------------- ,r��)<' t! -•--- -----c�. °�C- [�rl�• -r-t. -f' .� �i �f' '- — .7 / Date INSPECTION B --- -�' . --------------------- ........ ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Masetton Ave. 300 West Oak Street n% .+4 x124 Sycamo're.Stree! 205 West 9th Street Stockton,California Lodi,California Manteca,Califo nia Tracy,California E3i 9 REVISED 9-59 3M 3-•63 F.A-GD. 11