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'FOk OFFICE USE.. =' �. . �_3a- :'o c' Permit No. . ---------- APPLICATION POR SANITATION PERMIT (/ -------"---------------------- ' Date issued --- --------- --- (Complete in Duplicatey ----------------------- _ �. Th-i P mit Ex fires 1 Year From Date issued = -: , Application is hereby made to Lha Sari Joaquin Local Health District 49 a permit to construct and install}he work herein describe . This application is made in compliance#with County Ordinance Na. JOB ADDRESS4ANLOCATION rs/..------- Phone---- -----"------ ---- Owner's Name :5 3 S _-••- l/ Phone.. Address----- ------ r Motel ❑ Other ❑ i Contractor's Name._- --.- r i Commercial ❑ Trailer Court ❑ I Installation will serve: Residence �partment House ❑ p a -/ 7.. -- --------- t Number of baths __._ __..Lot size Number of living nits: __I_____ Number of bedrooms __ Private ❑ Depth to Water Table _ f# Water Supply: Public system [s��ommuriityystem ❑ Adobe�ardpan ❑ PPy� Gravel ❑ Sandy Loam ❑ C1ay.Loam ❑ Clay ❑ ew..Construction: Yes �No ❑ FHA/VA Yes ❑ No [�� Character of soil +o a depth of 3 feet: r Sand ❑. Application Made: (If Yes,date-__------- :- 1 No �� I Previous App r I ION AND SPECIFICATIONS: TYPE OF INSTALLAT ' 'ublic sewer is available within 200 feet.) (No septic tank or cesspool permitted if p Material_ o�_ •_ Dista from nearest wel4.----�`-------Distancf > f°Xndti�q�d depth-------•- ------------ ,Capacity ----- '------, ► Sep{ic Tank: r Size No. of compartmen#s_.�-- ------------ - Width of trench _. '__.s- t Field: Distance from nearest well_.._-"---=-Distance from foundation__lt+!_�--------Distance to nearest lot fine_________________ ---- Disposalr ------------Length of each line ==�47-------------- of lines------ -------- -.Total length-------- --------------------------- Number .6' I e + Type bf filter material--.�4-�=�----:-•--Depth of filter material----��-r,------ i Distance to nearest welL__�-------------D's}ante from foundation__�!�-_----_-----Distance to nearest lot line_.___._.-__--•- � L��Size: Diameter--,3-3---r--------.Depth-.-_rr -.r3-�---------------- Seepage Pit: r -------------- Number of pits"---------'--------=Lining material----- -- -- - -�- , . t gals. _Li Liquid Capacity -Linin materia------------------------------------- M__ ---------- ---- ----- Cesspool: Distance fi•om nearest well-�-------- ----•Distance from foundation_---_-- -- - q g -------------•------- --- ' Size: Diameter = ---- -------------Depth_.------ ------------------------ z Distance from nearest building_ ❑ , -------- 7 Privy: Distance from nearest well---- ------------ ----------------- ❑ ------------------------------------ Distance .to.nearest lot fine_ -------------------------------- t ,. . Remodeling and/or repairing (de�.�cribe)------ --------------i ? ---------------------- --- --- - -- 11 ---------------------- ------" �' done ------ , ' hereby certify that I have prepared this appiict�e San Joaquin hLocalkHealth eDistr c}n accordance with San Joaquin County . 1h Y i ordinances, State laws, and rules#and regulations of (Owner and/or Contractor) I -------- ------ ------------- -------- - Sined ------------(Tit) ----------------------------------- -- ------- --------------------- ------------------------------------------ ui ---- �, y' of tan, showing size a ot, location of s stem in rela+ion to wells, buildings, etc., can be placed on reverse side). (�I ' t FOR DEPARTMENT USE-ONLY I - - DATE---- ------ -------------- A -- r� APPLICATION ACCEPTED BY_t __. o--'- ---- DATE------- -----"---------------------------- ---------- ----- t REVIEWED BY---------------------------------- ------'"-- ------------ ---------------------------•-- ----- DATE --------------------------------------------- REVIEWED PERMIT ISSUED------ ----- - (�= 1 -------------- - Alterations and/ recommendations:_ ------------- ---------- ---------------------------------- t --------- ------------- ------- ----- --- ------ - Y - �ti•r MP Date---- ._ _ ._ _ FINAL INSPECTION BY---- --------- t-"' SAN JOAQUIN LOCAL HEALTH DISTRICT 124 Sycamore Street 205 West 9th Street 300 West Oak Street Tracy,California 1601 E.Maxeltan Ave. Manteca,California Stockton,California [ Lodi,California ES 4 REVISEd B-59 3M 3-'63 F.P.CO.