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OR OFl=10E USE: _ ------ ------ --_ APPLICATION M. R SANITATION PERMIT Permit No. _o.7,3k l - ----------------------- r (Complete.in Duplicate) / ' Date Issued __-- -- '-f --------------- _____________ ___ This Permit Expires 1 Year From Date Issued # r Application is hereby made to the San Joaquin Local Health District for a permit to construct and installithe work herein described. This application is made in compliance with Count Ordinance No. 549. 1 JOB ADDRESS AND LOCATION "-!-__ � ' r Owner's Name---- =-i r :, ------------------- ---------- Phone -------------------------- Address------------------- . ------------•-----------------------•-•---------I._.._................ ---•-------------• ----------•-------•-------...--..----------------------•-------•- Contractor's Name f----- -- -------- T_' °" = Phone _ Installation will serve: Residence [ partment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living,units: ___I___ Number of bedrooms _;2,_ Number of baths Al--- Lot size -------_____-__-________--_._.____ Water Supply: Publ;clsystem �ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to!a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑� Adobe E5—Ra"rdpan ❑ Previous Application' Made: I I f yes,date------------------_) No New Const r ction: Yes ❑ No 2?--THA/VA: Yes ❑ No 2 ' TYPE OF INSTALLATION AND SPECIFICATIONS: ± (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sepf a k: Distance from nearest well______._________Distance from foundation____________________Mafieriai____________--_____--_---_______..__..________. s #Vo. of compartments Size ------------------------.._Liquid depth-------- ----Capacity----------------------- Mspo"sal eld: Distance from,nearest well------------------Distance from foundation__!_a__________.Distance to nearest lot line___`eL---------- Number of lines---- --- ----- ---- ---- Length of each line__ng�.----------------.Width of tBench_,_!9_-j_!r................... T e of filter,materi 3___ aa iyp dlil - /-__---Depth of filter material_fT_______-__-_-;Total leng # `_`- --- � � �3 --t o ---- - Number of pits-------- Linin materna___QL. .--------Size: Diameter- a-? .-' - _ _ f .- t nearest lot line--�---__---- S See it: Distance to well.__ ____. g Distance from foundation____1?__________.Distance to Depth__��,�_�!_____________ O Cesspool Distance from nearestiwell-----------------Distance from found tion--..----__--`____.Lining material______________ __"-__.___-_________- ❑ Ize: Diameter.----" ------------------- -----------Depth------------------- --- ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest 'welL______----------------------------_--------- ___Distance.from nearest building__________.__---_-__ ) s_._______:..____._. ❑ Distance to nearest lotline-------------------------------------------------- -------------------------------------------#-•----------------------------------- g ± - 1 0 Remodeling and/or repairing (describe):----- ------------------------------------------`------------------------------------------------------------------•----------------- �. 1 ____________________________________________________________________ ___________ ____________-------------------_----------------------__-.-_--_.______----___________._______________________________.__ a I ; ---- i---•-----------•- I hereby certify4hat`I have prepared this application and that theswork will be done in accordance with San Joaquin County ordinances, State laws, d r es and ula+ionsof the San Joaquin Local Health District. r (Signed)---------------•- ------ - --_ ' N - '` (Owner and/or Contractor( E By:----------------- `----------- _- - `--------- .......... ------------ .................. ---------- ----•--- (Title)--- ' ----------------- -------------..-------- (Plot plan, showing size of lot, location of system.in relation to wells, buildings,/etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY i E i APPLICATION ACCEPTED BY--------- '---------=-------- ----------- '-------=-------------------- DATE----- ---------------------- REVIEWED -- ----------------- REVIEWEQBY ------------------------------------ t ------------ -------------------------------------------- DATE---------------- DATE BUILDING PERMIT ISSUED - �,.. -- " ---- �----"----- '•.---.-_ ------------ _ ____ ___________� Alterations,and/or recommendations:_._.___ ��:�----- ..- cs----- --------------- ' c ` i 1 f 9 ------------------------------------ -------------------------------- ---------------------•------------------ ----------------------- ------------- --------------------- ----------------- ----- ----------------I— ----------- ---------------- ------------------------ ------------------------------- r f �. ----------------------------------------------`--------------•-----------•---------------------------------•-"----•------------------------------------- ------- FINAL INSPECTION BY:. = Date--- ----I----- .../ t� ------: 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 ES 9 REVIBEO B-59 3M 3•'63 F.P.CC.