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FOR OFFICE USE: ----------------- ------ ------ ------------- -- - ------------------- ---- ------------------------------- - R APPLICATION FOR SANITATION PERMIT Permit No, ---------I-III'- (Complete in Duplicate) Date Issued - -------------------------------------------- This Permit Expires 1 Year From Date Issued " Application is hereby made t, the San Joaquin Local Health District for a permit to construct and instpil the work herein described. This application is made in compliance with County Ordinance No. 549. 02 (r/7 JOB ADDRESS AND LOCATION. -- ------------------ ------------------------- . -------- ----------- ------ Owner's N 112 y -- ---------------- ----------------- -------- Z-------------- ------------------- ------------ Phone-----•--------- ----------- - T ------------------------------- Address-- il--- 11___,;� � Contractor's Name-.--- ----------------r--------C.... ---------------------------------------------------------- - 01 It -- -------- ------------ Phone.---------------------------- Installation will serve: Residan'ce partment House E] Commercial L] Trailer Court El Motel E] Other L] Number of living units : '" ----- Number of bedrooms �__.Numbef of baths Lot size )(_4;92�---------------- Water Supply: Public system 1 El Community system E]" Private Depth to Wafer Table /---5�ff� ��f XCharacter of soil to a �depfh 3 feet: Sand El Gravel 0 Sandy Loam El Clay Loam 0 Clay El AdobeHardpan 0 Previous Application Made:' (If yes,date--------------- ----- No New Construction: Yes tNo E] F H A A.�YEl�N o TYPE OF INSTALLATION AND SPECIFICATIONS: ql. (No septic tank or cesspool permitted if pyblicpwer is available within 200 feet.) e D' f f7om fountuio/n a ria--- -------1�,� 14) Septic Tank: Distance 11orn, nearest w 140 ____.-_-.Mat 1 �7 No. of compartmorifs'.-Pl— ---Size , KID-X-2..__._Liquid --------Ca paci fy.12_0:�23- - -------k--"- 71 d clep�h------ Dis I Field: Distance fforri nearest we,, - -- ---------Distance from foundation____,'��_______Distance to nearest lot line Number lines 71- 7 Length of each line--- ;,/-'Width of trench------ ----------------- Type of filter mate Depth of filter material- 9- ------------Total length--------1-2— ---------------• - Seepage Pit: Distance to nearest well----------------------Distance from foundation___----------------Distance to nearest lot line__________._.____1 El Number o4 pits----------------------Lining material-----------------*--...Size: Diameter---------------------- Depth-------.-----------------.------ Cesspool: epth-------------- ------------ Cesspool: Distance from nearest well_________________Distance from foundation_._-__.-__--------- Lining material__-_______________-______--____,__. ii. Size: Dia m' efer--------------------------------------Depth------------------;----------- ----------------------Liquid-Capacity—-------------------- El P'iVy. ___Distanceft•onni-nearest well—------------------------- ------------ 'Dlsfance from nearest building------------------------------ --------- El Distance 4 nearest lot line-------------- -- ------------------------------------- Remodeling and/or repairing describe):-------- --------------------------------------------------------------------I---------------------------------------------------------- ------------------I------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------ --------------------------------------- ---------------------------------------------------------------------- ----------------------I---------------------------------------------------------- i 1.11 -Ile I herebycertify +hat 16 prepared this application nd that the work will.bP,done in accordance with San Joaquin County ared *h ordinances, State and—rulespend regulations of n Joaquin Local He /District. ............ (Signed)--- ------------ ----Le--------- -- ------------------- -------- ------ ----- -----------------------------------------------{Owner and/or Contractor) By------------------ -----11 ------------ ------------------------------------------------------------------ -------------------------(Title)------- ------------------------(Title)------- ------------------ ---------------- - - -- -------- (Plot plan, showing size of lot,! oca'tio!n of system in relation to wells, 6 ildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY_ ------------ --- --------------------------------------------- DATE ------------ ------------------- REVIEWED BY-------------------------- -------- ---------------------------------------------------------- -- --- ------------------------------------------------- - BUILDING PERMIT ISSUED-- - ------- - -A 6- DATE-----/_ DATE-------- ___ Alterations and/or recornmenAtions:-- --- ------- ----------------------------------------------------------- --------------------------------------------------:111,------------------------------------- - -------------------- j ----------------------------------------Ill:--------------------- -- - ------------------------------------------------------------------------------------------------------------------ ----------------------------- --------------------------- ------ -------------- -------- ------------------------------------------------------------- ---- ------------------------------------ --------- ----- ------------------------- -- ------1111------------- -- -------------- ------------------- ------------------*-------------- -------------- - --------------------- ------------------ ------------------------------------- FINAL INSPECTION BY---------------- --------------------- ------------------------ Date- ---------------4 ---2,1 2- ........... . -------- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street ;- 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 r.P.100,