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FOR OFF ICEyUSE: Permit No. _.. ._ 1 APPLICATION FOR SANITATION PERMIT ....... ........ - ------ ---- ..---J------- ---�------ i� (Complete in Duplicate) Qate Issued ...._s_. --1}{ ----------------------- --- I This Permit Ex ices 1 Year From Date Issued _ � Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i This application is made in compliance with County Ordinance No. 549. 1 i ► JOB ADDRESS AND LO ATION I II� �P' =------------------`---•--------------•----....--------------------------------- Owner's Name------ - -----•--------------------••------------------'------------'----------- Phone ... Address. --------•----;------•----............ Contractor's Name--------- -- - ---_--- -----------#---+----------~----- .... Phone I! ----------•------- i Installation will serve: Residence Apartment House E] Commercial E] Trailer Court Motel [3 Other [3r f a ®� I Number of living units: '---!Lot of bedrooms . Number of baths _. _-__,Lat ____._._--••-••••••••- Water Supply: Public systemf ❑iCommunity'system ❑ Private Depth To Water Tal le y�ft. 9 Character of soil to a depth of 3-feeEl Sand Gravel F] Sandy Loam El Clay Loam❑ Clay ❑ Adobeo Hardpan ❑- t t k s Previous Application Made: '{If yes,dote--------------------) No ElNew Construction: Yes E] No F}iA/VA: Yes El No El TYPE OF INSTALLATION AND SPECIFICATIONS: # r t (No septic tank or cesspool permitted-if public sewer is available within 200 feet.) # Dt r � r nearest well-----------------Distance from foundation---------_-------- .Material---------.---------_ .......................... tib No. of compartments--------------------------Size------ - Liquid depth-----------------1--------Capacity-----------------,•--- s Disposal Fie d: Distance'from nearest well _Distance from foundation.- _d--------.Distance to nearest lot line.... .._.... Number of lines--------�----_----- ------- -Length of each line---------------�4_.__--Width-of trench---..�--�-..-----------j---.--- , Type of filter mafierisl._ 1._ Depth of filter material-- .(--------Total length------------ ------ -Q---------- Seepage Pit: Distanceto nearest well ____Distance fo ndation--_�_.Q........Distance to nearest lot line................. �}"'� Number of -its �"` --,Depth---iR-al----•------------- P �" `-_-Lining material.-.. :Size: Diameter----�.� Cesspool: Distance from nearest well- _--_------_-.Distance from foundation--------------------Lining material__-..-.----._-----.--_--_-_•---_.--. ' P 3 ❑ Size: Diameter'L------------------------ ----------Depth-------------------------- - --------.-Liquid Capacity ---------------gals- Privy: Distance Distance fr nearest well------------------------------------------------Distance-from nearest building-----.----------------------_------------- ❑ II ! ! 1 lot line-------------------------------------------------------------- - F 9 / repairing (describe): ----------------------- --------------------------------------------------------------- -`----------------------.-..------------------------------ ------------------------------------------.---- Remodelin and/or re alnn des , f. t = ----------1-1 ir ----------•------------------------- -----------''-----..-------------••-•------------------------•--------------•-••-------_--- r s _ r� 1 i i ---••-•-------------------------•------------------------- -------------------- ---------_------•--------------------------- i I'her y certi y that I have prepared this application and that.the work will be}done in accordance with San Joaquin County ordinanc aws, antrules ar egulations of the San Joaquin�ocal Health District, s f _s � / Contractor) {Signedl -- -------- ------ -------------- nor art ---Title- _ or ci -_ (Plot plan, showing size of lot_, location of system in relation to wel buildings, etc., can be placed an reverse side). F FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED' BY_�� __ --- ----- DATE--- '_ _ .__-------- REVIEWED BY-----------------'------- " -' ------ ------ ------ ---_-----------._ DATE---------------- ----- -------------------------- - BUILDING PERMIT ISSUED `...-.._a--- -, :; _Dr4 - --- -- ----- � . . / -- -- Alterations and/or recommendations:-----� � - -�; -K'-- �.. �,T .-... �- i -------------------------------------- '--------••---------------- -•---------------- --- ---------------------- � .. Z -; 4 -.---..-----••-------------•__.---.-.---_-_-_..--...---•-----------------_..-.------------- --------------------- --------..-...--------------------------------------------------------------.------------------------------ Rd ------------------------------ ------- -------- 7--------------- - ------------------ ------------ - ------------------ I------------- •---•----- ----- 0 FINAL INSPECTION Y: ...... Date---f-- ------ J- ------ SAN AQUI LOCAL HEALTH DISTRICT ,130 South American Stud I 300 West Oak Stre t 124 Sycamore Street 205 West 9th Street ' Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 13-59 2M 5-62.ATLAS o f 1 IY f