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FOR OFXICE UtE: <br /> --------------------------------------------------- r• s <br /> _-.-_------------------- APPLICATION FOR- SANITATION PERMIT Permit No. . 1d._. <br /> ----------------------------------------- -- (Complete in Duplicate) <br /> This Permit Ex Date Issued <br /> ni---- �d- Tres 1 Year From Date Issued <br /> Application is hereby made to the San FJoaquin Local Health District for a permit to construct and install the ork hereinddescribed. <br /> This application is made in compliance. with <br /> `County�Ordinance No. 549. ' YM�.}(v"ii eC6, <br /> Al <br /> JOB ADDRESS AND <br /> �pLOCATION.......... F= N!— -- -------A <br /> ---- J ----- r--- --------- -- ---------- <br /> Phone---------------------Name----------�f ' -------- h �?_ __�� -- ---- ------ --------- - --�----- Phone. - <br /> Address------- �Q �� �` -----•- � '------------------ `-- -------t-----------------------------•--.......----• <br /> Contractor's ------W?----------- U-"------------ --------- Phone!B -. _1 2, <br /> Installation will serve: :Residence III- Apartment House E] Commercial ❑ xT�a ler Court�0 <br /> Motel Other E] <br /> ¢ Number of living units: _C_.__ Number-of bedroo s _ _ Number of baths :/____ Lot size _1_.-��_.--.-- _____________ <br /> Water Supply: Public system ❑ Community system <br /> NPrivate Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sanely Loam ❑ Clay Loam ❑VClay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--__---------------J No �ew Construction: Yes �/Iglo 1-1FHANA: Yes ❑ No kKK, <br /> TYPE,_OF INSTALLATION,=AN_D4,SPECIFICATIONS: <br /> e�Avail�ble <br /> _, .�(No septic tanlE�o�icesspo�a�lpermit+ed i# public sewerwithin 200 feet.) + <br /> Septic Tank: Distance from nearest well------------------- Distanc�elfrom foundation--------------------Material----------------------._.___________.._-_____-_-._ rv� <br /> (S i/14a No. of compartments----_-- __---------------Size'_4-- ' `_----------'_-........Liquid de th________________--_____.-Capacity <br /> Dis oval Field: Distance from nearest well--5 foundation.__ <br /> p �D. ______.Distance to nearest lot line______ <br /> ' ..,K......,k - rig„ each line -- ---- Fa----Width of trench- _ �. <br /> �"'Rf Number of lines"'�'" ~---- e tl; of <br /> e}- ��• Type-of fiite'r-material-=- _G y"Depth of"'filter.material------- -----------Total length---------------------7-0----------- <br /> Seepa� e�Pit: Distance to nearest.well---':------- __Dista ce�from foundation--------------------Distance to nearest lot line__._________---_- ?. <br /> 0 Number of pits----------------------Lining material)---------------------Size: Diameter------------------.-----.Dertfl!t'------------------------------ _ <br /> Cesspool: Distance from nearest well_______________-Distance from foundation___________--------_;•L'mingmaerial--------------.----------------------- 5, <br /> Size: Diameter--------------------------------------De thA:--------------------------------------------?Liquid Capacity __gals. <br /> Privy: ._ Distance from nearest.well-----------------------------------------•------Distanc from near�t building--------------.-------------------------- <br /> 1` <br /> ❑ Distance to nearest lot line-------- ------ -------- -------------•---j-------------------------- -----------------------------------------------. -------- ------- l� <br /> Remodeling and/or repairing (describe)- ''"AT .ar} IS-�s---- ------------- ---------"--------�---- ---------•----`---------- ------------- ------ ----------------•---------------- <br /> x L(4 <br /> -----------------------------------------------_---__-----------------------------------------------------`____ ___ <br /> -----------------------------------I------------------------------------------------------------ �--------------------------'-- e. <br /> yf- - --------------_--------------------------------------___-.-------------- <br /> t f i. <br /> I hereby certify-#hat I have prepared this application and=that thl work will be done in accord a ncel with San Joaquin County <br /> ordinances, St �aws, and rule nd regulations of +he San Joa {uin ocal Health;Distric+7 E# IEr <br /> {Signed) , a�/`"�-- - - ------ Owner and/or Contractor <br /> _._ (Title)--------------- _ . — - <br /> (Plot plan, showing size of lot, location of system.in relation.to wells,.buildings, etc.,can be_placed,on reverse side). <br /> FOR DEPARTMENT U5E ONLY <br /> > <br /> APPLICATION ACCEPTED BY----- [ --------- -- ------------ -------------------------- DATE-------{ �- -_- - ---- <br /> REVIEWEDBY--------------------------------------------- ---------------------- ------------------------------- -------------- DATE----.----------------------------------------------------- <br /> BUILDING-PERMIT,ISSUED--- --------—­__-_,_=_:=-- - <br /> - ----_----- ---------------------- -DATE------------ -------------------------------,_ . <br /> Alteratns d/orecomm andations:_ - <br /> --- -- ----------- ----------------- - ---------------------------•--------------------- ------•-----•---•------------- -----.- --- <br /> - -- -••----------------------•----- ---------------------------------------------------------------0.1-------- % _WAIT--------------------------------------- <br /> ---------------- --------------------------=-------•-------------- ----------•------------------•----------------------------------- -----------------------------•------------------------------------------------------- <br /> �-------------- ----- ---- --- ------ -----•-------•--•--------------------- ---------------------------------------------------- <br /> FINAL INSPECTI Date--------lUC_ ^ '2 -- ---- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stocklon,California Lodi,California Manteca,California Tracy,California <br /> Es 9 REVISED 9-59 3M 3-163 F.P.CC, <br />