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v vrrlLt ubt: _ .. s t / -- �" _--- APPLICATION FOR SANITATION PERMIT Permit No. _ : x (Complete in Duplicate) r """ ---- ------ -""---" ------- ' This Permit Ex ires i Year From Date Issued r - � .- - Date Issued .71�-G� Application is hereby made to the San Joaquin Local Health District-for a permit to construct and install hew work h�ein described, !, This application is made in compliance with County Ordinance No.Y54 . c^�E '40 �y irri. 45.7 417W 4,.- ,�/ —oNFi�E,°t� JOB ADDRESS AND LOCATION--801X--2d"'j ��NDiF N- �" ,. Owner's Name------ -- ' ---- - � ' Address_ ------- ----- ------ ----------------------------------- - -------- Phone------------------- �1-�-s� -• ` = - ------------------------------------------------------------- ---•-------- Contractor's Name----- .- = '------------ ----- - -------•------- -- -----•----------- Installation will serve: Residence Apartment House ❑ Commercial [D -------------- •--- Phone"". Trailer ,court ., E] Motel ❑ Other E3Number of living units: -- Number of bedrooms __� Number of baths __t---- Lot size ---- Water Supply: Publics stem ....................❑ Community system ❑ Private _ Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel❑ s Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe ff Hardpan ❑ Previous Application Made: (If yes,date---------------------) 'No New Construction. Yes ❑ No N FHA/VA: Yes No TYPE OF INSTALLATION AND ❑ SPECIFICATIONS: (No septic tank or cesspool permitted-if-public sewer'is available within 200 feet,) R a Septic ank: Distance from nearest well=__-_--"-_-_ _--Distance from foundation--------------------Material_--"__--'____--__- ❑ No. of comparf encs.___ _.__--_ y Size--" '--- Liquid depth--------------------------Capacity------ - �N Disposal Field: Distance from nearest weil--"_S?S'-_---Distance'from foundation__-.-LQ-_'__""---Distance to nearest lot line-"•1�?o_---. rc � Number of fines-- ----/-- ---- Length of each fine--------- - -' ' Width"of tr'ench•---------� ------ Type of f`rlter.material-�s-_ :Depth of filter material_--""--"-/ .�" g ^J w. ..._..,.._ ---Total ,len length ------------=--=- 5_d-- ---- Seepage Pit: Distance to nearesf`well------ ¢"_' uta-slf Distance from foundation Distance to,nearesfi lot line __.___-___ Number of pits-_- .-/_. `_--__Lining material ,- _ j�Size: Diarrefer-"__ I } —� Cesspool: Disfance from nearest well---------------"_Distance from foundation"___-____ 'r Deptn_,-._-----__"_-----. _T1 Lining material----I-------------------------------- ------------------- ---------------- - Size: Diameter-----%--'----��-- �----- ------- Depth--------- �---- �^--- ----------•- I --------- ---- - - __Liquid•Capacity `------------- gals. Privy: Distance from nearest.welL { . ing_- __-,_ ❑ Distance to nearest lot line""-_-- -Distance from nearest build __- - -- � - � � i - r � ------------ ------"_--. ------------ - -------------------------=-- Remodeling,and/or---------------------------r---e---t-p------airing (describe):--_----- 4i_ �- -- - --•-------------------------------=------------ ----------------------- r - .e+ 1 _ . re P . I hereby certify that I have P ared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joa uin Local Health District. , l t (Signed)---••---•---- --�- - - -------- �� ' 1 4 # -_---_---_Ow er and/or- -------------- ( / Contractor) gY� -- -------------- --•--` i - {Title}------- • {Plat plan, showing size of.lot, locati n of system in relation to wells, buildings,.etc.,,can;be placed on reverse side). t � FOR DEPARTMENT U5E ONLY APPLICATION ACCEPTED BY-.---_ _; _ tom-=-Z �4 t REVIEWED BY = DATE 7 yc----- -- ----•-- w - - `-------- -—---- BUILDING PERMIT ISSUED -- k ) ----- ---- DATE----------------•-----••-------: - ---- » Alterations and/or recommendations:------- _ -- "" DATE--------------- t __ " < ' .... cis}t_ --fad. .................. �°�:= -. ---- - - -- ------------------ - i. t . ------------ ---- _-____-----4 ••--- --- - -------- -------------------------------- ----------- ------------------ - - - - FINAL INSPECTION BY:. . .--. - - --------------------------- - Date_. AN JOAQUIN LOCAL HEALTH DISTRICT v 1601 E.Harellon Ave. 00 West Oak Street 124 Sycamore Street Sloekton,-California Lodi,California 205 West 9th Street . Manteca,California TracyCalifornia ES 9 REVISED 8-59 3M 3-•S3 F.P.CO. +� , '