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FOR OFFICE USE: - ---------------- --------------------------------------- -------------------- ---------------------------------r.... APPLICATION FOR SANITATION PERMIT Permit No. -------------------:-------.--:--:-.----- --------- (Complete in Duplicatel. ------------------------------------------------------ --- This Permit Ex I Year From Date Issued Date Issued -------k- Application is hereby made.to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This n.adpj r _9.ppljcq�ion is p, n compliance with County Ordinance No. 549. r If JOB ADDRESS AM LOCATION,/410� Y------5, _4 Owner's Name---- - - - -- - ------------- --------------------------------- Phone----------------------------------- - - -------- -------------------- --- Address----, Contractor's ddress----- Contractor's Name ��y ,------- ---------- Phone----------------------------------- ------------------------------------------------------------------------------- - Installation will serve: Residence E] Apartment House. F] Commercial. 921Trailer Court 0 Motel [J Other 0 Number of living'units: Number of bedroom's '=_ Number of baths --/-- Lot size ------------------------------- Water Supply: Public system E] Community system E] Private ]Depth to Water Table Ali 'ft. Character of soil to a depth of 3 feet: Sand 920"Gravel El Sandy Loam E] Clay Loam E] Clay E] Adobe E] Hardpan E] Previous Application Made- {if yes,date----------------------I No 9?"*Ne'w Construction Yes 0 No WRO'�FHA/VA: Yes 0 No �, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank- or cesspool permitted if public sewer is available within 200 feet.) —— ;_ .-� C �a - '__- - - – — bisfance-�from-near 'a _:�? ----Mafe!� L- -4;- ----------- ep Tank: est w�I_I /XgOv.etistancr'efrom=fou_n_da� OF tion- ------------- No. of compartments-_-AV-------------------Size__A.;V!�k_4(e7 Liquid clep�h----- -------�Capacity-_Bm- --------- 0 r .0-- !1 Disposal Field: Distance nearest well- --Distance from founclation.__0�9--------Distance to nearest lot Number of lines___-____- _..._. Length of each line___/VP .......Width of tren,hA' ------------------- Type of filter materialDepth of filter material- CAP----------Total length---.-OZW------------------------- 9 Seepage Pit: Distance to nearest-well-----------------------Distance from foundation-------- ......rDistance to nearest lot line_------__-__.-._. N 17711 umber.of pits------------------------Lining material-----------------------Size: Diameter----------------_--.-_-1Depth-._----------------_------- . ZC Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_----------------------------------- - ❑ Size: Diameter---------- - ----------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. - Privy: Distance from nedrest.weli---------------- --------------------------------Disfance.from nearest building._____.______-____--_-_--________..____._. N ❑ uilding------------------------------------------ 0 Distance to rieare.st,lot line.-------- ---------------------------------- ------ ------------------------------------------------------------------------------------ Remodeling and/or repairing (describe[):---- ----- --- ------ ---------------------- ------------ - - -----------24 ---- --- ---------------- ----- ----------------- ------------------ ------------ -----------/-------- .......4!ftK___e------- �_ ------ --------------- - ------- r ---------------------------------------- ------ --------------------------- -----------------=----------r------------------ ------------------------------------------------------------------------------------- ------ I 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 re.gulat!pns of the San Joaquin Local Health District. ll (Signed)-----------L -IEFFF"r Contractor) ---- -- -- - ------- ----- ---I- -------- -- ---------------------------------------- By:--------------------------------------------------------------- L. ------- ------------- -----------{Title)---e*;r _Z�------------ ------------ (Plot-ptan, showing; _size of lot, location.of,system in - ation to wells. buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED .BY-------------=---- ------ ---- ---------- -----------------------------0514V DATE---------------ot_�---;4------r REVIEWED BY--------- 4 -------------- ---------------------I--------------------------------- ------------------------ -------------- DATE BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------------- --------- DATE------------------------------------------- Alterations and/or recommendations:-------------------------- --------------- ------------------------------------------------------------------------------- --------------------------- ---------------------------------------------------------------------------- -- ------------------------------------------------------------------------------------------------ ----------------- --------------------------- --------------------------------------------------------------------------------------------------------------------------------- -------- --------------------------------------------------------------------------------- ---------------------------------------------------------------- -------------------------------------------------------------------------------- ------------ -------------- ---------------------------------------- ---------------------- ---------------- - --------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- FINAL INSPECTION IN BY_- w ------------------- Date---- -- _/-------------------- --- --------------- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISED B-59 3M 3-63 P,F.100.