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FOR OFFICE USE: --- -------- APPLICATION FOR-SANITATION PERMIT Permit No. ...�..C�.... ------------ ----------------- (Complete in Duplicate) ----------��------ --- --------------------------------- � Date issued ----•:•-- �--��i S ------------M - _ . • - it Year From Date Issued This Permet Expires 1 Y_ Application is hereby made to the San Joaquin 'Local Healf0District for a permit to construct and install the work herein described. TH'is application is made in compliance with County Ordinance No."549. �(�f fSo C( f `f0� AB B ADDRESS AND LOCATION_NoGr__!�___—.A-e-e- `�-_.-_---_ k- b�------- �. � � � OwnersName-- -- ------------- --Ld.l---- - - --- ------- -------- ---------------------------------- Phone--------------------•-----------•-- Address--Jov `-'' - p Contractor's Name------- ---- ----•- --•-- ------------------------------ Phone----- ---------------•------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --- Number of bedrooms<..—_ __ Number of baths -2-""Lot size ---------------------- Water Supply: Public system ❑ Community system ❑ Private 2f Depth to Water Table _______ ft. w r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [J°� Clay Loam ❑ Clay ❑ ,,Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date__-----------------) No El New Construction AYes ❑ No E] No FHA/VA: Ye [] - x` [] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank ar cesspool permitted if public sewer is available within 200 feet.)s Septic ank: Distance from nearest well___?"--Distance.from foundation------f0------.Mate.4rsal____-_�s'-'�------------------ -- No. of compartments-----s�-_.____.__.._Size_�Z�_/_p_X:fF:...Liquid depth-----/----------------Capacity__j,=2AQQ_ D'ispos ield: Distance from nearest well---?'t`..O_".._.Distance from foundation----10......___.Distance to'nearest lot line-__.____: Number of lines-------t�- J __________Length of each line------ _____'.Width of trench. .`_____________________..� Type of.filter material_=�J_��_:---------Depth of filter material_____ _m__:-.Total length__- ----------------------- S epage --___________________-Seepage Pit: Distance to nearest well----------------------Distance from foundation--------t---'----..Distance to nearest lot line__-_----------- ._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------r_----------Depth------r._ __-___---------------- Cesspool: Distance from nearest well_________________Distance from foundation__..-' ______-___Lining material_____.__-__-_________________________ ❑ Size: Diameter-------------------------:------------Depth_--------------------------- --------------------_Liquid Capacity-. -::---- -gals. I I ,Privy:' Diitance;from'.nedrest.well-e-_---___________ ___________________________Distance from.nearest ---------------------------------.4{�V ❑ Distance to nearest lot line----------------- -------------------------------------------- ------ -------------------------" ,-----------------------------•---------------------------- -------- R ---- ( ` Remodeling and/or repairing describe}:__F--------------- ---------- =------------•------------•----------------••--------------------------------- -----;--------•----------------------i C5 -------------------------------------------------------------•-------------------------------------------------------- ------ ' r`a t ' - -------------------•.---- _ - ----------------••---------- ----------------------------------------------------------------------------------------------- --•----•---- ------- ------ C. � ! hereby certify that I Have prepared this applica#ion and that the work will be done in accordance with San Joaquin County o`�clinances, State laws, and rules-and regulations of the San Joaquin Local Health District. (Signed) f -- -- -- rand/or Contract y {igTitle): ----- -------� ----. ------- y: 1 ----------------------------------------------- (Pot T � --------�- - - ------- (Pot plan, showing size of lot-location of'system in.rela n to wells, buildings, efc., can be placed on reverse side). fI' k w FOR DEPARTMENT USE ONLY A6LlCAT10N ACCEPTED BY.__._ __ !', r _ - . : DATE G17. ` --------------------------- REVIEWED -BY------------------------------------- -- -------------------------------------------- -----'------------------------=---- DATE--------------------7�--•------------------------------------ Bt�ILDING PERMIT ISSUED _. - - DATE ------ I f Alterations and/or recommendations:. ------ ---=s - --f `---'----` --------------•-••----------"•----------------------------------•---- ---- h --------------------------------------------- --------•------------------------=--------------------- ---------------•-------------------------------------------------- ------------------------------------------------ M----•---------------------------- -- ---- ---=----- ------ ------ - ---------------------------------- --- ------ ------------------ -•- -------•------------- ---------------- -------------------------•-------- .• ------------------ -------------------------------------------- FINAL INSPECTION BY:...... -L9t ,-_._f ---------------- Date-- ------------- --- - --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California y. ES 9 REVISED 8-59 3M 3•163 r-P.c D.