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FOR OFFICE USE: ---------------------------------------------------- ------ ----------------------------------_ APPLICATION FOR SANITATION PERMIT Permit No. .......f�........`.... 3 ` ------ --------------- - (Complete in Duplicate) --- --- This Permit Expires 1 Year From Date Issued ao !' Date Issued -.-- 5! 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 County Ordinance No. 549. I f JOB ADDRESS .AN LQ,CATION. !'E �C _ + (. Owner's'` ame-- Phone C�I1'�-17 - mss rt -•------..-•--- ------------------------------------ Address •---------• - - - Address----------- $77 ---A---- _ Contractor's Name---------- r v mss' - Phone----•-••---••-------------••------- A Installation will serve: Residence I Apartment House Commercial;❑ Trailer Court E] Motel [I Other ❑ S Number of living units: --J--. Number of bedrooms Number of bathsLot size _---.- r , /° : Water Supply: Public system E] Community system ❑ Private e Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑. Gravel ❑ Sandy Loal ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date___,_.`.'. . --- _) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Dis} nce rom mare #�}we!-��-B-i-r--_-Distance from foundation---------O-----r- ----Mater ial-_--- Noco art s-)- - � --- Liquid de th-------� Capacity....r-----------�--- ,..--,�••--�---.---d._-Q------j-�-'{•. ' V Dispos I Field: Distance from nearest well.-__•Sb-....Distance from foundation----1 --------_ N _ - .Distance to nearest lot Gne_-$--..---_-... e Number of lines-!--------. .-.- _---------Len $4 gth,of;each line------ .- ----------------Width of trench---- ---•---------------------- Type of filter me, oftr Total length (J -..j Seepage Pit: Distance to nearest well--------------_------Distance from foundation--------.-----------Distance to nearest lot line--- ----_ � ❑ Number of pits--``••-----------------Lining material-----------------------Size: Diameter-----------------------Depth--- ------=-------------.---------..--j Cesspool: Distance from nearest well----------------- from foundation___--_----------_..Lining material---------__-_:-_---.- ` ------------ ❑ Size: Diameter--- --------------------------------.Depth----------------------- ------------------------ Liquid Capacity----------------------------gals, Privy: Distance from nearest well--------------_.-------------------._-----------Distance from nearest building------------------------------------------(1 ❑ Distance to .nearest lot line____--------------------------_...----- - ------------------------------- ---------- Remodeling and/or repairing (describe)------------------------------------------------------------ 1 ` ------------•--••------------•------- -----------•-----=-- -1•---•-••-•---•------------- -----------------••------------------------------ --------- --------.------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State allawand rules and regulations of the San Joaquin Local Health District. Signed( � ) ter and/or Contractor] ------- -- ------------------- ----------- BY� :. .. r -•----- - - (Title) { (Plot plan, showing size of lot, location of system in relation o wells,:buildings, etc., can be placed on reverse side). { I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- �- --- - -a - - - -- ---------------------------------------------- DATE---14/1-- m-��•-- --------- REV I WED BY-------------------- ------------i--------------------------------------------------------------------------- ------------- DATE = BUILDING PERMIT ISSUED ... ------------------------ - DA•TE- Alterations and/or recommendations----------- ------------------------- -----------------------•--•---------------------------•----------------- �----•- ------------------------------------------------ - --• . -----•------•------------------------------•-------------•-----------•--- - ----------------------------------------------------------------•------- --- -----••---------------------------------------------------•------------------------------------------------------------- ------ --------•------------ --------- --------------------------------------- --------------- .. -------------------------•------- --------•---------• -------- ------------------------- FINAL INSPECTION BY:-- a - /f J!�L -��.--•�"� ------ - Date- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Are. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lotti,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 f.P.120.