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FOR OFFICE USE: -------------------- 1 _ APPLICATION- FOR SANITATION PERMIT Permit No. ___...---.______ �' --� (Complete in Duplicate) Date issued ..-��A: A-+ ___,.------------------"-------____._______._.__.____.;__ This Permit Expires 1 Year From Date Issued i rti Application is hereby made to the San Joaquin Local Health District for s permit to construct and ihstall:the work herein described. This application is made in compliance with County Ordinance No. 549.1 - r ;s 01l . � r ; -OCATION._ � --•--------- --- JOB ADDRESS AND r ------------- ' Phone-----------_ -----------_.-__----- Owner's Name ----------------- f = ` _____________________________Address----- -- '- 4f:! - ,Contractor's Name` Phone Installation wll serve:��Residence Apartment House [] Commercial ❑; Trailer Court ❑. Motel ❑ Other ❑ ' Number of living.,uriits. _ --- Number of bedroom's _ + _ Number of baths°�/-_ Lot size _ ----- ---------- ------------ Water Supply: Public system ®Community system ❑ Private ❑ Depth to'Water Table tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam-E] CI yoam ❑ Clay❑ Adobe @a-'11ardpan ❑ Previous Application,Made:_(If yes,,.date_ ------------------) No 9?0�New Const�uction::Yes ❑ No R1 Yes ❑ No E9 TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic stank or cesspool permitted if public sewer is available within 200 Jfeet.)i6<r� Septic_Tzinky Distance from nearest!well-----------------Distance from foundation.-----------------Material----._-_---- .-------_----.----.._----. f.AdAg�p No. of compartments-l------------------------Size------------------------ -------Liquid dePfih ;)-_?`~ -----=�- ,-ppcity- ------------------- Disposal Fiejd: Distance from nearestjwell_.__. '___._.Distance from foundation-----101V----.-.Distance to nearest!lot,line.471 --------- Number of lines._-___-1r__ __ Length of each line__ f 7 9 JN,dth of trench..., ti ig ' l Type of filter material_��_ Depth of filter material__ _______--.Total length-- �___rf____________,f._______ 0 i R , I t / 5e age i, Distance to nearest well*_---_-_.--Distance fro fou�idation_-_--�V----_--.Dist�rle to nearest lotelin -------------- 0 Number of pits.__::__-----_-_-_-Lining material___ Q_ ttl."Size:'Diameter- "£:__.Depth_��•�r, __________________ r I - Lining material------- ------------------ Ce spo Distance f�•om nearest well-----------------Distance from foundation.-.______________ _ I � ❑ Size: Diameter----_------------- -- - Depth � ----- ------------------Liquid Capacity- .-l----_----------------gals. Privy: D.isfance from nearest well------------------------------- ------------------Distance from nearest building------------'__-_�--"-_-----____--._----. ❑ Distance to nearest lot lire------ ---------------------- ------------------------------------------•--- --------- f------------------------ 4� Remodeling and/or repairing (describe): .,__- ---- A ----- /' --------------------------- I --- ------- -------- ��- �------------------- ------ _ __ - ---------- ------------------------- ------------------------------------ ,may --------......--�--=---=-• I hereby certify that I have prepared this application and fKat the work will be done in accordance with San`-Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. � � 1� Contractor)(Si (Signed) �A"� ---------- - -------------- ----- - --- ----- - 4 . --•-_(Title).... 14Z^-- +.� (Plot plan, showing.size of lot, location of system in relatio o wells„buildings,,.etc.,-can.bewplaced..on!reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_.._- -_._ -------------- tREVIEWED BY-------------------------- - ------ DATE----------------------------- ----------------------- BUILDINGPERMIT ISSUED------------- --------------------------------------------------- ---------------------------- DANE--------------------------- `--------------- -------------- Alteratiod/o recommendatio s---- ---------------- --------------- ---------•------------------------------ -.�'--------------------------- -� ° P" - --- - -- -- - .---------- -------------------------------------------------•------------------------------------------ � . ---------- -- --� ------:---- - -- ------------ ------------- ------------ -------------- --------------------------------------------------------------------------------------------------------------------------- ------------------------------ FINAL INSPECTION BY;------- ✓.<!_t 1 -------------- Date.--------- --------- ---------------------------------------- SAN OAQUIWLO�AL'-HEALTH DISTRICT 1601 E.Hazelloo Ave. 300 West Oak Street 124 Sycamore Street _ 20 West-9th Street. � n ' Stockton,California Lodi,California Manteca,California Tracy,Califon a EB 9 REVISED B-59 31,4 3-'63 F.P.CC.