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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. __��-�---•f- -"------------------"--- (Complete in Duplicate) Date Issued ---- ----_ - This Permit Expires 1 Year From Date Issued --------------------- -------- ---- r. l Application is hereby made to the San Joaquin Local Health District for a permif to construct and install the work herein described. I This application is made in compliance with'County Ordinance No, 4 JOB ADDRESS AND LO CATION.... - '=-------------------=--------------------- Phone-- --------------- ------------ - --: -_- - .- - ------- ---" Owners Name----�- ----•• -----•--- --- - =----•------- ---:----------------�---- --- ------•-- -=--------- --------------- 117AI oAddress=fk ------------------------------------ ne .._ -•--- - Contractor's Name------ �1 Installation will serve: Residence & partment House ❑ Commercial E] Trailer Court [IMotel ❑ Other ❑ � Number of living units: __�__ Number of bedrooms,_?_ Number of baths : Lot size -` " Depth to Water Table"---- ft. Water .Supply: Public system ❑ Community Sys temPrivate ❑ P � dn ❑ b Adoe arpa Character of soil to a depth of 3 feet: Sand ❑ Gravel.❑ Sandy Loam ❑ Clay Loam [IClay E] o E]Previous Application Made: (if yes,date--_"---------------1 No 9f, New Construction: Yes �/1�30_❑ FHA/VA: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` /� _ � -----------.Material__4r_ ' Septic Tank: Distance from nearest we :_ �_"----Distance_ Tom f yindation Size X-Wl-Liquld depth ! P acityZ p --------- i No. of eom artments_ Field: Distance from nearest well._:.'• 'p_ Distance from foundation__ - W`dthcofttrenchQs ------------------------- Disposal s� __ "-_ Len th of each line-_- "" '-- Number of lines-_ -�+.*--= g /� . i Type of filter material�l,/'�FVu Depth of filter matenaL"�>�."•---�--,Total length"--_�"___ � v'' - 0�------- p -."-.Distance to nearest lot lin`" _"" Seepag Pit: Distance to neares# well----- ... .:�;-`- Distance fr m foundation _ De th - .-:-- -,� Size: Diameter- p - Nurner_of-pits"'", _"..rLining material"" _ ---------- ------------- Cesspool: Distance from nearest well----------------I-Distance from foundation__-._.__"_ Lining material_"", f ---------gals. DepthLiquid Ca oticY--- ------------ ❑ Size: Diameter------------------- ---- 1 f I Distance from nearest well---------------------- ------- --Distance from nearest building_--__-_------------------------- ------ Privy: - ---------------- ❑ ---------- - - Distance to nearest lot line...--.."___"- '"- r _ . Remodeling and/ repairing (describe):----------- ---------------------------------------------y� -------- 4' ------------ ----------------------------------------- - -- - ------ ----- -------------------------- ---- l ly' ! hereby certify that I kava 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�5an_Joaquin Local Health District. " �+. f Contract / yf -- - ------------------ r or) (5igned)- /y ------------- ��Titie) �`�'`11 E✓d - By:_---------------------------`----------------- �. �---j7'� g p (Plot plan, showing size of lob;location-afsys+. _ to relation to wells, buili�in s;-etc., can be faced on reverse side). { F EPARTMEN SE ONLY ' ---- -- -� ----------------- DATE- - - •� - - ------- ----- APPLICATION ACCEPTED B --- --- - ----- --- ------ ---------------•-------------------- --------- ------ --- --------- DATE------------- -----• ------------------------------------ REVIEWED ------------- ------------------ REVIEWED BY------------------------------------------------------ -__--- ---------------------t ---------- BUILDING PERMIT ISSUED -------------__-.- Alterations and/or recommendations:"_ -------------- ---------------- 4 - ---------- ------------------- Date---- h--- ----- - - - -- FINAL INSPECTION BY:.. SAN JOQUIN LO L HEALTH DISTRICT - *124 Sycamore Street 5 we$�4th Street 1601 E.Ha:elion Ave. " 30o West Oak Street F Lodi,California M a . anteca,California Tracy,California IJ Stockton,California ' • ; '� £5 9 REVISED 6.59 31A 3-'63 F.P.CD. '