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AOR OFFICE USE: - .. APPLICATION FOR SANITATION PERMIT Permit No. -...-r_ 3- (Complete I4in Duplicate - ------- ------- -- -- -- ------------- N --------- This Permit Ex fres Year From Date Issued Date Issued - r Application is hereby made to the San Joaquin Local Health Dislirict for a permit to construct and install the work herein described. Thi ppliication,is,made in compliance with County Ordinance o. 549- JOB ADDRESSD LPCATI,ON , .- - C - -----------------------7_e ?; Owner's Name__9 �! ------ -- -------------------- ----------------- -------------- ---- Phone-- 4�e?__-614_!3_ Address-----------•-- Contractor's Name - K rIke €-- -------------------------------------------------------------- Phone Installation will serve: Residence Apartment House Commercial ❑ ��tt� P ❑ ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ---(-_-_ Number of bedrooms _pR y. g y ❑ �-_ �tuber of baths _ ' - � �-. Lot size .-1-t?U a (.,�-' Water Su I • Publics stem Community system ❑ Private K Depth to Water Table i Character of soil to a depth of 3 feet: Sand D9 Gravel ❑ Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------..-----..--.} No ❑ New Construction: Yes [K No E] FHA/VA: Yes E] No E]Y TYPE OF INSTALLATION`AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)..K # Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material ---------__--_------------ ❑. No. of compartments ---- -------- -----Size--- ---------------------- -•-Liquid depth-------------------------Capacity ----------------------- Disposa cold: Distance from nearest well_--.�( -i_Distance from foundation_---JA!.......Distance to nearest lot line-___5___1-_--- i Number of lines------1-------------------- ---Length of each line----�_�-----------------Width of trench--A-:-�-----------____-- ' -Type of filter material- G «- �f'Depth!f filter material--_-/�........Total length-------- �---------------+ Seepage Pit: Distance to nearest well----�'-----Distance�,from foundation--------------------Distance to nearest lot line-_--------,--_--- ❑_ _ f Number of pits---------------------Lining 'material-__5-------------------Size: Diameter-----------------------.Depth-----------------•------ -__ -_ Cesspool:: Distance from nearest well-----------------Distance"from foundation-------------------- material------------------------------------- ------------------ __--------_-::--____ I' ❑' ------------•- Size: Diameter------------------ -- ------------ Depth ' ---------=--€--------------------------------Liquid Capacity----------------------- ---gals. i •: Privy: Distance from nearest well- ----------------- -- --- k --------------.1�1-Distance from nearest buildin _ __ _ - ❑ Distance to nearest lot line--------- - ---�---------__---_ - ------------------------------- - Re deli an ------ or L/--'re- 'a_---i�r--- �-�.---.�----- ----- '1 - - -� - '------fit - - ----- --------------s ,-,�r�� l Ilex 6ti t I h prepared this tion and th r/�� f Y Y P P PP Wet the work will be done in accordance with San Joaquin County ordinances, State I ws, and rules and regulat ns of the San Joaquin Local Health District. 9 (Signed} t ----- - ------------- --------- - s: ...`. - Owner /or Contractor)'}_ ( P B E ---------------------------tion to ` ,----- _ Plot Ian, showingof lot, location of system to rely • ----------------- -_�r--------- (Plot y eIIs, buildings, etc., can be placed on reverse side). I� FOR DEPARTMENT USE ONLY } I: APPLICATION ACCEPTED --------- $ IM------------------- --------------- = - - --------------------------- - REVIEWED BY "� ------------- DATE BUILDING PERMIT ISSUED------------------------------- ----------------------------1_11------------------------------------ DAZE - Alterations and/or recommendations:--------------------------------- i ------------------- --------------------•---------------•------- -------- , - --------------------------------------------------- •----------------------•--------------------------------------------- - ------------- ---------------------------- ------------- ---------- ------- :--------------------------------------- •-------------------------------------- -------------------------- - FINAL -- - FINAL INSPECTION BY: ' Date-- ` i 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 REVISED 6-59 .3M 3-'63 F.A.Cp. II'