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A, FOR, OFFICE USE: ------ -------------------- -_.______--- APPLICATION FOR SANITATION PERMIT --------------•------------ --------------------- -----'--- (Complete in Duplicate) / -------------------- This Permit Ex ires 1 Year F om to lssa Date I d I Application is hereby made to the Sa*J�an cal Health istrict p r uF I II or ein described. ` This applIcatio is made n compl Or. C,e6o. 49. JOB ADDRE S ANDS /0 ATION---- -•----- �------�------ ------- -- ----------------- Name------••- A>� _ - �"''.:--�--...-�i-;------ ---- --- ------- -----------------------� --�-- ,:X'� �44_-Ph_o" e.--------....:........._...----- A !f Address .. . -•----•-•-----•- Contractor's Name________________________ _ - r -------------------- Phone................................... Installation will serve: Residence ❑ Apartment House5 ommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:;4 Number of bedrooms __ Number of baths,�_._l'>___ Lot size _-D.-45-4---- .... _ Water Supply: Public system ❑ Community system ❑ Private Depth To Water Table4. _Q ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy --Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (if yes,date--------------------) No [/New Construction: Yes ' No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: No sap t or c sp �l e mi 7d if pp l�'t�c As is available within 00 feet.) �. ' S Id. r �' s m d 1 istance rom nearest well -------Distance from fgndat.on_______-..._.___.__.Materia--------------•--------•--...-- r ❑ No. of compartments--------------------------Size-----------------------•-------Liquid depth--------------------------Capacity-----................. Disposal Field: Distance from nearest well-J` ---- Distance from foundation___J ----------Distance to nearest lot line--___�..�. IKJ _ .._ Number of lines_______.____ Length of each line_.��4_________________Width of trench...____�-.`l____.____._--__-__- Type of filter material._/__ __ ___ De th of filter material_.___/1...____._.Total length....... _�r�- __�_____.....__ � [ P Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_______..._...... ❑ Number of pits______________________Lining material-----------------------Size: Diameter_-.________.____ _ - - Depth------------------;--....------- t Cesspool: Distance from nearest well_________________Distance from foundation____-_____.____----. Lining material___--------------------- ------------ 3 ❑ Size: Diameter---------------:----------------------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. Privy: r Distance from nearest well________________________________________________Distance from nearest building-------------------.----------- ❑ Distance to nearest lot line Remodeling and/or repairing (describe)----------------------------• -- -- ' ---- -- . ------------------------------------ - -- - A.0. . I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta a laws, and rule d regulations of the San Joaquin Local Health District. (Signed) -- --- --------- pwner'en r Contractor ---- ------------------------ --- - --- d/o or By: .... {Tit e) _(------------------------------------------- (Plat plan, showing size of lot, location of system to relation to well';buildings, etc., can be placed on reverse side). -,x FO EPARTMENT USE ONLY APPLICATION ACCEPTED BY-----,- ---� ------ -�--�-�"'-=�=-=--y----------------------------------------- DATE------- ---G.••. --------•---------- REVIEWEDBY----------------- --------------------------------------------------------------- -------------------------------------•-•--- DATE -------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------••------------------------ •---•--- DATE...........------------------- _ Alterat' ns and r recon d'at' _______ ___ _______.._ ------ ....................---------- ,_ y g- - .e.�------ -- --- • ------ - :_, 6- ._ ---{'— ---�--- r,�--tom - - /'� f� /G3 FINAL INSPECTION BY: ------ - ---------- Date---•- ;- gy ��SAN JOA�7, N LOCAL HEALTH DISTRICT 130.Soutl4American Street -300 Wast Oak Streetmore Street .Stro t:3 205.We Ih • - Stockfon,Californi24 Syca a �� Lodi,CaliforniaCaiifiManteca,California Traey,:ial yy `! ES 9 fiEVISEO 5-59 ZM 5-62 ATLAS - �,