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......................................................... --�� nnQQ q,�ICATION FOR SANITATION PER Permit No. V-_Laf?L.. ---------4 - (Complete in Duplicate) - ' Date Issued . .....:/.7-G` _ .. ............._._..............._ ................... This Permit Expires 1 Year From 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 LOCATI N.....__ Ky .. �.......................... �-- ...... . — -E -- ------......•----....... Pf/ho�ne --4--�..f_..---.--------•-•----.'Owner's Name r-11+ ! . --'----- '---.Address- Contractor's Name.. - - ..........---..................---------- -----'--'-"--"•-"---•-'•-- ............ Phone._----•-•------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ...._... Number of bedroomss.:..___. Number of baths .. dot size .___. 4-e. fl lo-Zn Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Teble '?j:_.. �� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay,1' Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date....................I No 4 New Construction: Yes No ❑ FHA/VA: Yes ❑ No (x TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic 1(v1� Tank: Distance from nearest well--- _IP....-..0____Dist° n oon._._1-42._......M terial -___. No. of compartments------y .....Size...C.. f r or OU Liquid depth Ca ac� t Discal Field: Distance from nearest well----70.....Distance from foundation......'.Q......Distance to nearest lot Number of lines.....__ _ __ _____ Length of each line------- Q ---t--I----Width of trench----- &_01.......... . Doph of filter material------ length_.._._.____ � ........_.._... Type of filter materia .... rVe l Seepage Pit: Distance to nearest well....-----------------Distance from foundation....................Distance to nearest lot line....... ❑ Number of pits......................Lining material...------.-------------Size: Diameter------------------------Depth---------------------------._... Cesspool: Distance from nearest well.................Distance from foundation....................Lining material------------------_......_._.... ❑ Size: Diameter . --'----_-._.............Depth-----------------------------------------------Liquid Capacity...........................gals. Privy: Distance from nearest well.................................................Distance from nearest building.............................._..._...__. ❑ Distance to nearest lot line--------------------------- ------------------_---------------------------------------------------------------------------- Remodeling and/or repairing (describe):-- -------------- 1 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 Distri (Signed)---..��„A��CE ......----.�--- --- -- --- -- --- - .. ------ -----. -.(Owner end/or Contractor) -"- " .................. W ---- '--- '- - --'------------------- - --_(Title)-- ' ------------------------- -- - - (Plot plan, showing size of let, fixation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---.......'-'..................................----- ..... --" / ... DATE REVIEWEDBY----------------------------------------'- -.............._---- - - - ...lY.... DATE--- ' BUILDING PERMIT ISSUED...--......"......------......... V T�' -'------ ------------------------- -•--------------------... DATE---- -------------------------- ------------------- - Alterations and/or recommendationsc......---.............'----" .."'-•--'---'--'------'_.._........•••••-........................--••--.-.......................................... -------'--....-''--'--...... . .. .................----........_...---------------.............----...............................................................-...................................... -------------------------------------------'----------------------'--....................-....................-'---"-- '----------------......--...... ....................-----......------------"-- '------------'-------_._...---' ..... -----"----'------------------------------------------------'-"--.......---'----.. ......... -------------------------------------------------------------- J -< - -------------------------- ...... ...-------•------------------------------------------------ ~ /FINAL INSPECTION BY:_.......-...... -_::a Date"---------' .............. _... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hare lion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi, California Manteca,California Tracy,California En 9 REVISED 9-59 3M 3 '63