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fvR Vrrll,-k USt: - p � `--- �o APPLICATION F(3{t SANITATION PERMIT PermitNoo - om . ----------------- 't (Complete in Duplicate) This Permit Ex fires 1 Year From Date Issued - 'Date°Issued Application is hereby made to the San'Joaquin Local Health District for a permit to construct a t ThIs application is made in compliance with County Ord' nce No. 549. and install the work herein described. JOB ADDRESS LOCA112N,. ' ~` Owner's - ------- Address__.. --- ----- Phone Contractor's Name_-- Installation will serve: Residence ----- ----------------------------- Phone,_____�Pf�'- l �artment House ❑ Commercial Number of living units: _��uriity er of bedrooms ___ Trailer Court ❑ Motel ❑ Other El of baths ___--/Lot size ) ! Water Supply: � �� ----1-��_------- Character Public system s stem Y ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand Gravel EJ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe Hard a 1, .Gravel Application Made: {If yes,date------- P n ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 No New Construction: Yes [] NO �A�— Yes ❑ No ❑ (No septic nk or cesspool permitted if ,public sewer is available within 200 feet.) tic D p Distance from nearest well_-------------_Distance from foundation______-___________".Material.-____.______ No. of compartments-----------"------- ize-------•_--- - ----------------Liquid depth--------------------------Capacity Distance from nearest well-- .- Distance from foundation._ Capacity____.___ Number of lines__.__ _.- --_ -/•-0---------Distance to nearest lot ----- ------Length of each line___A&P -� -�' Type of filter materia - -Width of trench." --�j --__Depth of filter material___-- �+' �---"-" ------* Seep a Pit: Distance to near t well__ _- Total length__.__________________O Distant rom undation_ Distance to nearest lot line__._---------------- --------------Number of pits__: -- = Lining material_ _0 /. Size Diameter_. Cesspool: Depth _ i J ❑p Distance from nearest well_________________Distance from f, ndafiion--_- _____--__-.Lining material_--__.-____--___.__.______--_____-_ !� Size: Diameter_______________-"_--_ ' R- w ----------------Depth-----------------------------------------------------Liquid Capacity gals. OQ Priv -�`�'."".... Y: Distance from nearest well---_ ______ _: _,_----": ---- - ------ buildin ;❑ Distance to nearest lot line------"__--_-- _ __ � rs-ante from nearest n - . _--------------------------------------- ---------- ReTodeli ---- - -- ------- emodeling and/or repairing (describe):-___ W ---- -- ------ ----- ---------------- x ------------------------- --------------------------------------------------- --------__------_-------___________________________________________________________._____.�. ... - ____________________________________________________________________________________________________________________________ .s f I her e t s, I have prepared this application and that the-work will be done in accordance with San Joaquin Coantyt ordinances, t ws,eft a rules regulafio of'fhe'SSn Joa ain �s _ Ith District. (Signed)----- ea q �. .Y r Contractor Y� ------•-- ----- ------------ - ----------------. ------------------- )Title)------ -------------------------------------- I - i (Plot plan, showing size of lot, Iocatian of system in relation wells buildin s c., can be placed an reverse side). g ' ` FOR DEPARTMENT USE ONLY l APPLICATION ACCEPTED BY_--_-__ -_ _-- /,,• , ua _-- ------ DATE-- REVIEWED BY--- a''S _UE '= -" '�`* - s s, .. . .,w. i y,-------------- =- D BUILDING PERMITrISSUED---n- �"-'�• - - ------------------- - --- ---- ATE __�_. Alterations and/or recommendations --- 1 �" ------ DATE- -- --- � � .- ---------t--- *' --•- t ----------------"- x - a _ - -- -- - - - ---------- ---------- -------- ------- --------------------- ---------- INSPECTION BY: '_ - �� , / 7 � �! Date = � N - --------------- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E,Hazelt*n Ave. 300 West Oak Street 124 Sycamore Street Stockton,California Lodi,California ' 205 West 9th Street Manteca California Tracy,California ES 4 REVISED 8-59 3M 3-1b3