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FOR OFFICE USE: --------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. _..� / . ----------------- -------------- - ------------- ------- (Complete in Duplicate) �/ 6 -------------- ------------ -------------------------- This Permit Ex fres 1 Year From Date Issued - Date Issued .... 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. JOB ADDRESS AND LOCATION----------- �1-_ r Owner's Name------------------ 7?----------------•------------ ---------------------------- Phone,,/� ,�- ? Address --------------• flu=---••-.. L�� -G(dti4 c �1 f Contractor's Name------- -------------------- ........��-f.T--------------------------------------------------------------------------------------- Phone.................................... ' Installation will serve: Residence &' Apartment House-E] Commercial F] Trailer Court ❑ Motel [IOther ElNumber of living units: L_ Number of bedrooms._off_. Number of baths _-/--:- Lot size ----..�_ .........x( !�_�_____ I Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 'Feet: Sand ❑ Graved ❑ Sand Loam Clay Loam; �""Clay, • Y ❑ Y ❑ y ❑ -Adobe❑' Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--- o l'� Distance ft'om foundation-==_.-- Cj-,_ Material=______ cP/ No. of compartments-------`2- ------------Size--- X� S Liquid depth �� Capacity Disposal Field: Distance from nearest well......5---__..-.,Distance from- ® - ; foundation..---—0_ -_----Distance:to near-est lot line_-------S Number lines ----_-_-_---.._ hlWidth trench Type of fltermaterial_--.--��__Depthoffltematerial-a 1$` _._ tal length -1f -- � --- Seepage Pi i t rlr Distance to nearest well ---------------------- 40M foundation_--____._-- Distance to nearest lot line----------------- Number of pits----------- ------Lining material-----------------------Size: Diameter---------------- -Depth--------------------------------- Cesspool- Cess ool: Distance from nearest well-----------------Distance from foundation._------------ ---lining material---__---._--.-.------------_•-- ❑ Size: Diameter----------------------- --------------iDepth------------ i -------------------------- ----Liquid Capacity--=_-----------------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildin6 ❑ Distance to nearest lot fine emo eling and/ re airm (des I be}:_:-.__--_--__.--- ----------------------------- ::::; = •-------------------------- - -------------- ------------------------------ �, _..-__ _- I hereby certify'f#'f I have prepared this'`application and that the work will be done in accordance with San Joaquin County ordinances, State"law , and rules and regulations of the San Joaquin Local Health District. . 1 .(Signed)----x--- -- ----d �� .-_:`''- ---------------------••-----•--- (Owner and/or Contractor) r: By----------------------- -------•---------------------•------------------------ '-------------------•---------------------------------(Title)---------- ---------------------------- -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FO DEPAR MENT USE ONLY -------- APPLICATION ACCEPTED BY----- -- -- -- -- t_ ___-------------___-- DATE------�� --- _9---� -------- ----------- --------------- - -- REVIEWED BY A., DATE = •----- --------------- ---------•------------------• BUILDING PERMIT ISSUEDDATE --------------------- ------------- ---------------- Alterations and/or recommendations--------------------------- ------------------- �` ----_---•-------- •-- - --- -- __-.. �� _ ---------------------------------------------••----------------------_.---- ..--------- " r ___-.. •-•_-•---___- --------------•------•--------•-----•--•-----••- -----" FINAL INSPECTION BY_ ....... - - -- `- ----- ------------- --- ----- Date-- �----- 41��q-71-- 6 '•-�--- -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California-- . J _ Tracy,California EB-9 REVIBEfl 13-59 r.P.CO.2M 6.60 , '