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FOR OFFICE USE:/ _/ ' - 0 - APPLICATION FOR SANITATION PERMIT Permit No. ._1_4_1��•-�' ; (Complete in Duplicate) Date issued _______________________ -------------------------- " This Permit Expires l Year From Date Issued - Application is hereby made to the SaniJoaquin Local Health District for a permit to construct and install the work herein describe . This application is made in compliance jwith County Ordinance No. 549. .JOB ADDRESS AND LOCATION ��93 - � Phone�.�- owner's Name__.. ------- ---•-------•--------------- Address_... - `"""' -- - -------•-.._..._ Phone----------------------------------- ------------------------------------------------- --------... ------------------•----...._._.__.--------------•-- Other Contractor's Name_____.._Q_ Trailer Court ❑ Motel ❑ Installation will serve: Residence Apartment House ❑ Commercial ❑ Number of living units: __-I.__ Number of bedrooms __�__ Number of baths ---�-. Lot size ._____7�-•�-- � "" th To Water Table `��ft. - Water Supply: Public system ❑ Community system ❑ Private' " hep �/ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Q �-laY❑ ❑ C , FNA/VA: Yes ❑ No [ "" I - New on: Yes [�•o ❑ , Previous Application Made: (If yes,date__-------------- 1 No i TYPE OF INSTALLATION AND SPECIFICATIONS: yi (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept' Tank• Distance from nearest well_________________Distance from foundation__- ___.__.-t -.Material..--- Ca aci Size ------------------ Liquid dep p tY•--- f { tee/ ~� No. of compartments__--_. s Distance from nearest well__g�_,--.--Distance from foundation..fv--•--•----•Distance to t neareslot lin e......_:--.•--..- Dis al --.-Length of each line_____�?�-----------•---Width of trench._.___. --fir Number of lines-1 ---- ---- '--- g - --.".Total length_-----��--•--------•---•----------- G' '-_ ---.Depth of filter material___f t ----� �r Type of filter material..._. --- << Depth-- 2`S `.. Seepage Pit: Distance to nearest welf_1 ----------Distance_foundation_._ C�____.---_Distance t-- nearest o Inc_________________ --Linin material..--•---IC --e-tS'sze: Diameter--- ❑/" Number of pits--------�_______-- g Cesspool: Distance from nearest well______._____..-_Distance from foundation____________________Lining material------------------------------------- Cesspool: I Depth Liquid Capacity -------••--••---•---•---•g ❑ Size: Diameter._I p s g Distance from nearest well------------------------------ -Distance from nearest buil in Privy: -- ----•- ------------------- ❑ Distance to nearest lot ine____________________ .. ------------------------•----•---•--------------------------------------•----•------------•--------•- ' Remodeling and/or repairing describe}----------------------- ----- ------ . ---•- 1 -------•-----------••-----•------••---------------------- -------------------------------------------------------------•----- � pplication and that the work will be done in accordance with San Joaquin County I hereby certify that I have prepared this a ordinances, State laws, and rules anti re lations of the San Joaquin Local Health District. { l __(Owner and/or Contractor) 5i ned _ . - ----------- ( 9 - ---------------- •------- ---• - - BY� } --------------------------- ---(Title)--------------------------- (Piot plan, showing size of to , location of s stem in relation to wells,'buildings, etc., can be placed an reverse side). i FOR DEPARTMENT USE ONLY DATE..--�= '-- 6 a�`' �-- ------------- APPLICATION ACCEPTED By • DATE------------•---------- --•---------------- REVIEWEDBY---------------------------------•------- --- D `; �� /- BUILDING PERMIT ISSUED.------• — DATE / ------/-• --- ....I------ . �- - --- - Alterations and/or recommendations:.__- S- --- ----- --•---••---•-------•---- •---------••-------------- •---- •----•------- - ------------ rr, O / .�' AA, G �� _ Date--- ----- ------------- --------------- FINAL INSPECTION BY:------ - --'--- --•--�-..._.- ----- ------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 124 Sycamore Street 205 West 9th Street 300 West Oak 5xeef Tracy,California 130 South Aoierican Street Manteca,California Stockton,California Lodi,California ES 9 REVISED 8-59 2M 5.62 ATLAS