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FOR !OFFICE USE: .--.5� ---- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ---------- ------- ----- This Permit Expires i Year From Date Issued -------- --- -Date Issued Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549- a�,. JOB ADDRESS AND LOCATION-------- -,-rx'7�J __ Owner's Name-:'_._-_- Addr �, . _ _ _ _ - ------------ -------------- ------ Phone------------------------------------ ess----------- py r •--•� -- Contractor's Name_____ -• •-----•--•------ '- --------------------------------------------------- Phone Installation will serve: Residence E? Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E] Number of living units: --_1---- Number of bedrooms �, Number of baths -------- Lot size _______ Water Su I : Public s stem PP Y y [r—Community system ❑ Private ❑ Depth to Water Table'------ ft. Character of soil to a depth of 3 feet: Sand C] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan F]Previous Application Made: (If yes,date:l@ 57-_} No ❑ New Construction: Yes No [�" FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within'200-feet:) t _ �"" ^1 Septic Tank Distance from neares#:well=_. ----_Distance romMfoundatfontpMaterial_._ ,�.r No. -Of compartments______..__ -- - -- -------- --� - �JN; ---- SizeX: r.apac Dis oeld: Distance from nearest well__- Q----,-.Distance from foundation ul/Pe th-_Distance to nee p � nearest line_--___,.. Q� Number of lines___,jLength of each line---I-__ - A Type of~filter material--_ Width of trench _2.__ Depth of filter.material____1�,________--Total length___. O' $eepa e�Pit' Olsten eto ne est well___/__- - Distance from foundation___.__-___ e J� Distance #o nearest lot line____ ___________ Number.of pits.---�' � � of ming material_i------,----Size: Diameters . _ - P Cesspool: Distance from nearest well__ ___Distance from foundation.__.___._--___ Lining material#-----171 ------------------------------ Size: Diameter- ---------------Depth--------------------- -------- - - I w -- ._Liquid Ca ------- r Priv --gals. Y Distance from nearest well --- --Distance from nearest building- Privy: uildin I I g ---------------------------- ----------------❑ Distance to nearest lot line_____ ,---_---- 1 ��, Remodeling and/or repairing (describe):__. - - � � _ • ' a E ______---__- ____________________________________________________1.---__.-_-.--_ -------------------------------- _-..-__..._____ __________________________________________________________________________________________________________________________________________•--- ___________ _______________________________________________________________________________________________________________________________________________________________________________________________________{___--.-__- I hereby certify that I have prepared this application and that the work will be done'in accordance with San Jos uin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. q Y I' (Signed)--- --=---- I nd --------- ----------------------- ------- --- O Y� } ----(Owner a /er Contractor ------------------------------------------------ -------------(Title)----------- C ) -- ---- (Plot plan, showing size of lot, location of;system,in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. - r DATE. lG� REVIEWED BY----- ----------------------- - -•------- -- - ----- �. DATE__ z ZZ WG PERMIT ISSUED -----------------------------------------------------'------- ------ DATE Alterations and/or recommendations:---1 Q-,-Z.. _--[P --------------------- ---------- Alterations ------ _ j—'* -lames ---•-.q va-----•---------- ------ ------------------ .,. ---------------------------•---------- -. -- FINAL INSPECTION BY:.--- -t.._.I-?"�---------------- --------- -- Date--- SAN -SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazellon Ave, 300 West Oak Street 724 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy, California ES 9 REVISED B-59 3M 3-'63 F.h.CD. .G I