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FOR OFFICE USE; le ------- ------------------------ ------- JM Permit No. ............ --------- t No. APPLICATION FOR SANITATION PERM[ n Duplicate) Date Issued ------------ ---------- - -------------- -------------------------��T--- (Complete ; V� --------- -- ----------- This Permit Expires.1 Year From Date Issued Application is hereby made to the SatrJoaquin Local Health District for a permit to construct and install the work herein described. I This application ise'ade-in compliance with County Ordinance No. 549. Pi ------------------------------------------------- JOB ADDRESS AND CATION-------- -- - ------ --------------------- -1_14a Z 's Name-------T ------- ------ --------- -------- Phone------------------------------------ Owner ------------ --- -- --------------- --- --------- - Address--------- -------_-- ------------------------------------------------------- Contractor's Name-------------- Phone -installation ----------------------------------- will serve: Residence Apartment House E] Commercial E3 Trailer Court El Motel 0 Other 0 Number of living units: Number of bedrooms,3..- Number of bat,&-2- ---- Lot size - ---------------- Water Supply: Public system El Com I munify system M- Private 0 Depth to Water Tabl&__�._ ft. Character of soil to a depth of 3 feet: Sand F --qardpan C1 ] Gravel [] Sandy Loam El Clay Loam E] Clay 0 Adobe W Previous Application Made: (if yes,dcite--------------------) No 114 �ew Construction, Yes Zk-lqo E] FHA/VA: Yes BP--I�o El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance'from.nearest wpS---r!!�__Distance from foundation/ ----------_--.-_.Material-_____.___,-----------------------F--------- ---- ----Size,- f-' ---Liquid ----Liquid depth-g� --Capi --------- No. of compartment ------- _/---W----------------- 1�� Disposal Field! D ------Distance to nearest lot line'_!-!t-------------N- " istance from nearest Distance fance from foundation R Number of lines-------c. --U-----------------Length of each -7----Width of trench ----------------------- Type of filter material- _�;.-h_ ,/ ... C-0 "/ ---- 15epth of filter material__ -------- .....Total length--- ------------------------7. Distance to nearest,well—vrr —"Mstan-c�f m. c ----------- !oun �Iafion---/---0.2---- Distan e to nearest lot See el__�__,A A/ Zk2 -_Depth Seep P/P Number of pits---- ------Lining material. ..O�C Sze- Diameter-A-- ---------- Cesspool: Distance from nearest weil-----------------Distance from foundation________________ ___Lining material_...___._____.__- .________________- ❑ aterial-------------------------------------- EJSize: Diameter----------------7 ---.Depth--------- ----------------------------------- --------Liquid Capacity----------------------......gals. Privy: apacity------------------------- Privy: Distance from nearest well---------------------------------------------- -Disfance from nearest building------------------------------------------ ❑ Distance to nearest lot line------------------------------- Remodeling ine:----------------- -------------Remodeling and/or. repairing (describe]:------ - ---- --- ------------------------------------------------- _Ie�_ _ ---------- ------------------------------------------------------------------------------------------- ------b--------------------------- ------------------------- ----------------------------------------------------------------- -------------------------------------------------------------11----------------------------------------------------------------------------------------------------------------------------- --------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- I hereby certify that I have prepared this application and that the work wild be done in accordance with Sa'n Joaquin County ordinances, State I rules ancrr-egulations of the San Joaquin Local Health District. (Owner and/or Contractor) (Signed)---------------- --- - ------ ------------- ---- --- ----- ------- ------------------------------------------------------ By:--------------- ------- ----i----------------- ---------------------------------------(Title)--- ------ ------------------- ize fat, location of system relation f o 'wells, buil ings', 5- etc., can be place on (Plot plan, showing in rel reverse,IS, a F DEPARTMEN SE ONL - - --------- ---- --------- APPLICATION ACCEPTED Y --- -- --- ---- ---- -- ----- ---- ------- --- - -------------- DATE-- ---- --- - - REVIEWEDBY-------------------------------- ------------ --- --------------------------- ---------------------- --------------------- DATE--------- ------ -- --------------------------------- BUILDING PERMIT ISSUED----------------- --- --------------------- ----b--------------- - -------- DATE------------------- -------1-------------------------- -- - --- ----- ---- - -- -- ----------------------------------------------------------------------------------- Alterations and/or recommendai ---------------------------------------------------------------------------------------------------- -------------------- ------------------------- ----- ------- ----------------------------------------------- ----------------------- ---------------------------- -- --------------------------------- --- ----------------------- ----------------------------------- --------------------------------------------------- ---------------------------- ---------- ----------------------------------------------------------------------------L-------- ----------Z---- -------------------------------------------------- ---------------------- --- ---------------- ------------ ------------------------------------------------- ----------------------- --------------------------------------- ---------------- FINAL INSPECTION ------------ Date---- t�o------------------------- B --- ------------- - -- ----- SAN OAQUI OCAL HEALTH DISTRICT 1601 X306-West Oak sj,;:ej 124 Sycamore Street 205 West 9th Street I. Stockton,California Lodi,California Manteca,California Tracy,California EG 9 REVISED B-59 3M 3-'63 F.PX0.