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FOR OFFICE USE: 44 - ---------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -.17��.. � ----------------- - - -------- --------- (Complete in Duplicate) ti ---------------_. This Permit Expires 1 Year From Date Issued Date Issued ._ _l-l�_ 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 Count Ordinance No. 549. �� 0�3 D�Q„_ Off• JOB AD ES NDD�//LOCATION---, ----- �,Q •e--------6- Owner's Name-----1941;6-----r�(.O --------- Phone------------------------------------ Address--- -C� �r c---------------------------------------- --------•-•-----------•-••--- Contractor's Name---------- �--- ••-------- Phone----------------------------------- Installation will serve: Residence Epartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l__ Number of bedrooms_ Number of baths Lot size _�� - __ .a. -!_------..--.. Water Supply: Public system ❑ Community system ❑ Private �th to Water Table 66- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (if yes,date........._,--------) No New Construction: Yes W No ❑ FHA/VA: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: / (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T : Distance from nearest well __-_-Distance from foundation__(1___ L.a _-_-__.Material- _c -_ _ ��C-_1~.__1[..-_____./ No. of compartments____-3----- _____Size- ___Liquid depth____. J..---------Capacity. .___. Disposal -e d: Distance from nearest weft.-.. _.t Distance from foundation___ ZQ!_Distance to nearest lot lin �___�------- Number of lines_--_4�__-r_._�. Length of each line--/- ---,. ._.Width of trench-___C ___ ___� - ype of filter material___- u�e0epth of filter material_____tf_�_!___-__.Total length_ _ _ __ ------------- Seepage i ; Distance to nearest well--- Distance m unciation__... ____-.Distance to nearest lot lin_ S'_ _____ Number of pits______ _ __Lining material___ _.-.Size: f Diameter_�2.9----__--Depth__a�____._._ Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material--------------------------------------- ❑ Size: Diameter-------------------------- ----------Depth- ------------ -------------------------------------Liquid Capacity----------------------------gals. , Privy: _______________Distance from nearest building-____-._______________________-___ ❑ Distance to nearest lot line-- --- -- ---------------------------------- --------------------------------------------------------------------------------------------a9 ).r% Remodeling and/or repairing (describer -% ---------- -------------'--------------------------------------------------------- -------------------------------------- ----------------------------------------"-•---=--------- ------------------ n�' -----------=------------------------------------------------- I3 ----------- --------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State w 'a d rulesrn eguiations of.the Sa.n Joactuin Local Health District. (Signed)-•-- ---------- = {Owner and/or Contractor) 7 BY� ---------------------------(Title) -- (Plot plan, showing size of to , to)a—flon of system in relation c we s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- -------------------- DATE --------------- REVIEWEDBY---------------------------------------------------------- -----��_.�-------------------------------------------- DATE-------- ---------------------- BUILDINGPERMIT ISSUED------------- --------------------------------------------------------------------1------------------ DATE---------------------------------------------------------- -- Alterations and/or recommendations----------------------- ----------- --------------------------------6 ------------------ ---------- ------------------------------------------------------ -------------------------------------- --------------------------------- --------------•--------------- -------- ------------------------•---------- ti FINAL INSPECTION BY: Date-?,- ----------------------- y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street s Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P.CC. ��