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FOR OFFICE USE: ----------------------- ------------------ ------------- .......... ---------------- --------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------I-------------------------- (Complete in Duplicate) Data Issued ---C------/..71 --- -----------------U__==W-Mm_m ! This Permit Expires 1 Year From Date Issued Application tion 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. JOB ADDRESS AND LOC VIW...... - -- ------- ------------------- Owner's ------------------ ......f---- -------------------- ----------------------M-M----------- Owner's Name4 -----------M....... Phone--------------------------------- Address hone---------------------------------Address -----------------------M--------_-------------___---------------------------------------------------------- ---- --------M------_------------------- Contractor's Name------ Phone. ... ...-.. Installation ------------------- will serve: Residence 2R"'Apartment House F] Commercial E] Trailer Court. ❑ Motel E] Other [I e __ - -, - Number of living units: Number of bedrooms -9-- Number of baths An.- Lot size Water Supply: Public system 2�Community system [:] Private E] Depth to Wafer Table'Yoff. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] Clay Loam El Clay E] Adobe Eq-14—ardpan ❑ Previous Application Made: (if yes,date----- -- -----I No � New Construction: Yes [:] No 2P-'FHA/VA: Yes El No TYPE-OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic,Tagk: Distance from nearest well_________________Distance from foundation___-________._-.---Material-_-------._.___._-__-_____._____------_--______- jo,,CKyij * No. of compartments------------------- ------Size.--------------------------- ---Liquid depth----------------- --------Capacity---------------------- D-i!,posal Fie4cl: Distance from nearest well-----------m-----Distance from foundation-------------------Distance to nearest lot line______---________ 91 jr ,F4,5H* Number of lines-----------------------------------Length of each line-_----------------------------Width of french------------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------MM---------------------- Seepage Pit: Distance to nearest well------?!!T=-------..Distance from fo9ndafion------ Distance to nearest lot Iine__.;_1i----- 95-- Number of pits----._-/------------Lining material_"-__eP4:;C...Si;e: Diameter___,d5f9_-__. ----Depth.__xW------------------------ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-_-_____..__--_._________-_._______,. ❑ aterial-------------------M--------- ------ E] Size: Diameter-------------------------------- -- -Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------_m-----__-_____--_Distance frorn nearest building-____.._____--_____________-------.___._. 171 Distance to nearest lot line.---- ----- ------------------------------------------------------------------------------- ------------ --------------------M--------------------------------MMM--------- Remodeling, and/or repairing (describe):----------- ---•---------------------------•------------------------------------MM--------------------------------------•----------------•-----i -------------------------------------------------------------- --------- ------ ----------------------------------------- -----------------------M--------------------------------------------------------------------M-------------------------M----------------------- --------------M--------------------------M-----------------------------M----M------------------------M----------- -------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of f e Sian Joaquin Local Health District. t [Signed)- m------ - ----- --- --- - -- --- _- --- ---------- --- ----------------------------------..(Owner and/or Contractor) By:----M------------- ------------------------------------------------------- - ------------ ----} ---------- - - ------ ----- (Plot plan,"showing size of lot, location of system in r n to wells, buildings, etc., can be placed on reverse side). FOR DEP" ENT ONLY APPLICATION ACCEPTED BY-. --- --------------------------.--. DATE- --------------------- REVIEWEDBY-----------------mm--------------------------------------MM-----------------------------------------------_----------------_-- DATE------------------------------M----------------------------- BUILDINGPERMIT ISSUED------------------- ---------------------------------- ------------------------------- -------------- DATE.----------------------------------------------------------- Alterationsand/or recommendations:__-------- --- ------- ----------------------------------------- --------------------------------------------------------------------------M---m------_ -- ----- ------ --- -- - ------ ---—------------------- ------------- --- --------—7 ---------------------------- - ----------- Cs ,t --- ---------------------- -- ------------ --------------- FINALINSPECTION BY:---------- ---------------------- ---------- ---------- Date-------- ----------- ---- -- ------------------------------- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxoltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 3M 3-'63 F.P-Co.