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FOR OFFICE USE: ---------------------- - ----------- -------------------- APPLICATION, FOR—SANITATION PERMIT Permit No. Z.................... --------------- -- -------------- ----- -- (Complete in Duplicate) -. This Permit Expires I Year From Date Issued 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. 2nq `.�,f X3.0�_„S. • �.A-�._ -....,r. f ?,. r�� a � � � � •�� JOB ADDRESS AND LOCATION_�2€ ' _ - -1------ __�-__ fi -- Q, Owner's -� 4 Owner's Name_.. � �Cd __�f %� Phone ----- Address------r(- Contractor's Nana 4 .• r�. ��1c ------------------------------------------------------------------- Phone----....... •------------------- Installation will serve: R s ante Apartment House ❑, Commercial ❑ Trai er Court ❑ Motel ❑ Other ❑ I----Number of living units: __l-_ _ Number of bedrooms _ Number of baths _t____ Lot size _--__..__ __ __ _ ________________________ ter----- Water Supply: Public system ❑ Community system ❑ PrivateX,,Depth to.Wafer Table __5--- ft. Character of soil to a depth of 3 feet: ' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ 1 Previous Application Made: (If yes,date--------------------) NOX New Construction: Yes &No ❑ rHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer.is available within 200 feet.) i Septic. Tank: Distance from nearest well:__--1-0-__Distance _ _ - from found�on---- 0------Ma er 4___ Siz x__,�--- Li Liquid de th___-_-- __ ------(No. of compartments----- _ _ -Ca acitY f . Disposal Field: Distance from nearp�t_well-j7!,<).--Distan'c`e from�founda ;on.---- ---------Distance to nearest lot line------ Number of lines-- _-_-.-- ---- ---------- Lengt4S oe�ii line.T�'_'�'Q_ �c�r Width of frenc •- -------- Type of filter material-_ [Depth of filter material---.- _ _---- -- Total length__.____�'1��__:`?____________________ : Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- 171 Number of pits----------------------Lining material----------------------"Size: Diameter.--.---------------------Depth----------------------,--_-----_- Cesspool: Distance from nearest well-----------------Distance from foundation--.--_----_---.-- Lining material---.---------------------------------- Size: Diameter------------------------------------"De-th-------------------------------------------- -------Li uid Ca acit -_ als. Privy: Distance from nearest well_------------------------------------------------Distance from nearest building-----------___-------_-___---_--_._---.__ ❑ Distance to nearest lot line ------------------------------------ -------------------------• - Remodeling and/or repairing (describe)=-- -------------- --------------------- - --•--------------------------------------------------------------------------•-------------------------------- -------------------------------------------------------------- ---------------------------------------------------------------------•----------------------------------------------------------------- ------. ----- 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 regulations of the,San Joaquin Local Health District. (Signed}--Cf- ---__ iZ- - - -------- ------(Owner and/or Contractor) By-----------------------------------------------------=------------------------------------------------------ ------------------------(Title)............................ --------- --------- . . ........ ....,................... 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). J! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------------------- ------------------------------------------------------------------------- DATE REVIEWEDBY------------------------- ---------------------.----------------------------------------I- ---------•----------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------"-------------------------------- Alterations and/or recommendations-----------------------------------------------------------------------------------------------------------------------••-----------••----------------- -----. -------.-•---------------------•--------------------•---------------------------------------------------------------------------------•-------------------------------------------------------------••---------------------- --------------------- --------------------------------=---•--•---------------------------------------------- ---•-------------------------------------I---------- --------------------- ------- ---------•-------------------- , FINAL INSPECTION BY: -------------------- ��!� Date f J ----------------------------------------------------- if SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California FS 9 REVISED B-59 3M 3-'63 P.p.CC.