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FOR OFFICE USE: ----------- ------ ------------------------------------- ---- ------ --------- --------- ----------------- APPLICATION --------- -------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------- --- --- ---- (Complete in Duplicate) --------------------------------------------------- ._. This Permit Expires 1 Year From Date Issued Data Issued '0 -ftiD ( Application is hereby made to the San Joaquin Local Health District for a perm' to eonstr r t eid insta the work her dlcribed. This application is made in compliance with County Ordinance No 49. Tt JOB'ADDRE' A LOCAT10 A t tlW t Owner's Name------ 1 `--- -- -- -------------- -------------------- ------ - ----------- --- -------- . Phon Address-------------------•--- /---- C. _ --- - --------- r f Contractor's Name. ----- --- -------- - -� Phone.. X* or Installation will'serve: Residence Iff Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ of living units: _1__- Number of bedrooms _._ Number of aths _______ Lot size Number .-.._ Water Supply: ?Public'system ❑ Community system ❑ Private Depth to ater Table ______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan [] Previous Application Made: [If yes,date---.__....__._-._._) No ❑ New'Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No ptic;tank or cesspool permitted if public sewer is available within 200 feet.) Se201No. of com artments_________ ______________Size f t 5 ^ m f�qundafi n-----I--a-------.Materia----- A- ptic ank: Distance from nearest well____`___ _�____-Dis}a ce fro �j P � - - �--�<----��Liquid depth-------�--------------Capacity--- �QrJ Dispo Field: Distance from nearest wefi-„� _......Distance from foundation_____ a__--._. Distance to nearest lot line__5__f____.__ [e Number of lines_______-__�'__`___ ,j�___ Length of each line-----/_dO____________Width of french___._Z__�___________________ Type of filter material___-_ ll� _. __-Depth of filter material_,._._-�_y__ --__Total length_-____ ------------------------ Seepage Q G______________s__________ Seepage Pit: Distance to near6st-wel]—-)_-__.-_ Distance from foundation--------------- Distance to nearest lot line----------------- 1K 171 j Number of pits--------------------_Lining material-----------------------Size: Diameter------------------------Depth-----.--------_--------_-------- Cesspool:• Distance from nearest well-----------------Distance from foundation____________________Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth---------------------------------------------*------.Liquid Capacity--------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance.from nearest building---------.-------------------------- ❑ 5 Distance to nearest lot line repaline-------- ---------- - f ------ -------- -----------------------------�- ------ -------------------- --- iring (describe)- - - ------ �"•---------•- �- ---------- ------------- --------- --#------------------------------------------------- ---- --- -- -- - r I hereby certify t all�ltive prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and r}ilgs and regulations Tofen Joaquin Local Health District. (Signed)= = I 0 _ r and/or Contractor) Piot !an� � = ------- ------- Title---------- ----------------------------- '-( p , showing site of lot, location of system ito we s, buildings, etc., can be placed on reverse side} FOR DEPARTMENT USE ONLY - - APPLICATION ACCEPTED BY- --- -- - - ---- ------------------------------------------------ DATE---- ---------------------------- REVI I EWEb BY----------------------------------- ----------------------------------------------- DATE------ -----------------------------••- --- -•------•------- BUIL � DING PERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE--------------------------------------- -------------------- Alterations and/or recommendations:-----_- -_-.-.. -- ---------------------------------------------------------------------- -- ----------- ------------ -------------------------------------------------------------------------------------------------------------------------- .1 .- -------------------------------------------------------- ---------------------------------------------------------_------------------------------------•-----------------------•------------------- --------------------------- y ---------------------------------------------------------------------•------ -------------------------------------------------------------- -----..-..----------------------------- ------------------------------------ 2— '7” ----------- ---- -- " � - ��sj FINAL.INSPEGTION`BY----- 32it ------------------- Date_- ---------- - .-- ----------------------------------------- r SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-S9 3M 3-'63 F.P.CO. f.