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— -�.�.-- r -------- ----I � -(6- --------------�0V---- APPLIC ATION FOR SANITATION PERMIT Permit.: .t ------------------------------------ (Complete in Duplicate) `,------_.. ----- This Permit Expires 1 Year From Date Issued Date Issue Application 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- ' S JOB ADDRESS AND ' CATIOI Owner's Name.---- --------- ------- --- - -- -- t -- --- •-- - - -•-"--------•---------------- - ----------------- - / --- --------- ----- ----- ----- Phone-- ---- ---------- -a- ...... - - - ----•"--- ontractor's Name -------- ---•---- Phone._�Ai ,3p � Installation will serve: Residence Apartment House ❑ Commercial ❑ �Trailer Court [J Motel ❑ Other ❑ Number of living units: 1---_ Number of bedrooms___ Number of baths f y, Water Supply: Public system ` Community system E] Private El Depth to Water Table Q_ ft Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ t Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,tdate,___-_____ _-_) Nov '�, ' 4 New Construction: Yes ❑ No DrFNA/VA: Yes ❑ Nok" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer tis ave!able within 200 feet,) Septic Tank: Distance from nearest we4J No. from foundation__.__________: __-. p * Material------------------------------------------------ meats t--------- Size-------- ------Liquid depth------------ Capacity Disposal Field: Distance from ni � � Y � � � - ----- "�" ----`-"----------- o, o com art earest well-____- ----___Distance from foundation__________________-Distance to nearest lot line_______________.. 1 ❑ Number of linesi----------------------------------Length of each line-----------------------------.Width of trench------------- ---------_ �J Type of filter mafierial-------------------------Depth of filter material______..___________--_Total length_____.__________.:________-_________ Seepage Pit: Distance to nearest wel_ _ � � r a / W �}�' "'--"" n-��__.._.__.Drstanct; to nearest lot line-_.�_.. i / "` ___Drsfiance-f�ori'r datio {dumber of pits'--____�_-________Lining materi i Size:.Diameter___--_ ------Depth- -----��"-----------• V Cesspool: Distance from nearest well-------------_- Dista a from'foundation__________________ - Lining material ------------ --------------- ❑ Size: Diameter---'---- ---------- ----'--- --------Depth-----------------------• ----- - - - - , i -------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-_.'--------..-------------------------------------Distance from nearest buiiding --------------------------------------- El Distance to nearest lot Gne'"�___-.._--_"_______-_-- ----------------- ----- -- __ _ Remodeling and/or repairing (describe):_____.-."-_�--__ F --, -. --------_----------------- - Q - --- ------ -_•---- -------------------------- --- ------ k. ------- ----------------------------------------------------------- --------------------- --===-------------------- 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 the San Joaquin Local Health pistrict. '' (Signed? , ------- + r =-------------------------------------------------`-------- -(Owner and/or Contractor) # �— By __�'---- - (Title) ' (Plot plan, showing size of lot, location of sy m in relation to wells, buildings, etc., can be placed on reverse side). , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y___.-_ "---__- ---- DATE------- REVIEWED BY----------------------------------- - - --------- - ---- -" ------- - --------- ------- -------- DATE---------PERMIT ISSUED------------- - -------------------------------- D Alterations and/or recommendations------------ ATE-_--------------------------------,-,------ ------- ----- y ------------- - ! -----------------------------------------------------------------•---------------------------------------------------------- ------------ ----- n ------------ ----------------------------------------------- --- -------------------------------------- FINAL INSPECTION BY:" --- -- ---C�--rte - �y Date--- --------- rAN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave- 00 Wes,Oak Street 124 Sycamore Street 205 West 91h Street Stockton,Colffornia Lodi,California Manteca,California Tracy, California �� /v5 9 REVI6 EG 8-59 3M 3-'63 F,p,e O. .