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FOR OFFICE USE: (� ' ------------------------------ ----- APPLICATION FOR SANITATION PERMIT Permit No. ....�..Ia - ---- _ M (Complete in Duplicate) _ .--- Date issued -" - -- ---------------- _ This Permit Expires 1 Year From Date Issued '- Application is hereby made to the San Joaquin Local Health Dice strriic for W/_ oa permit to construct and install the worl�stein describe . This application is made in compliance with C y ------------ ------------------- -- -------- =---- JOB ADDRESS AND LOCATION....-- -Phone - �/ � Owner s Name --- ----�-----------r`-�--- --------------------------••-----•-•-------------_-----:-------------------------- Address----e ...... '= 5 ------------------------------- Phone---------- Contractor's Name----------•--------------•-•------- •---------•---- - •- - - - - - - --------------- Commercial ❑ Trailer Court ❑ Motel [❑ Other ❑ Installation will serve: Residence b/ Apartment House El Number of baths J., Lot size ___ /- - - --- X-- Number of living units: _ .___ Number of bedrooms - / Water Supply: Public system Community system ❑ Private 12` Depth to Water Table _ __-_ ft. pp y� y ❑ Adobe., Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑FHA/VA: Yes 0� No ❑ Previous Application Made: ;If yes,date--------- --- - ---1 No [y New Construction: Yes ![ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) } /) � ` !`----- ----- Septic Tank: Distance from nearest well___ 'L"3-------Dize(r °foundation pth__M[ 8 ._- _Ca aci 12-A.--��------ 7from1f` p ty No. of compartments_V ._.Width of trench._= _1ne___��1 ------- v Disposal Field: Distance from nearest well_ Length of e h ine_' S_r- � G y f� _Distance frorri�f un_da ion_ �i- -` Distance to near � 4.�- -- Number of lines --------------------------- r7 L�/ Type of.filter material_t4.1_) 4%epth of filter.material---,- -.Total length------ ----------- Seepage Pit: Distance to nearest well____________________iD'sstance from foundafiion___.__...__.___.___.Distance to nearest lot line----------------- QS ❑ Number of pits---- --------Lining material------- ---------------Size: Diameter------------------------Depth-------- ------ Cesspool: Distance from nearest well_______-______-:Distance from foundation.__._______________Lining maternal_____--_-_____-__-____-________.__.. ls De th_----- -- ----- Li uid Ca Size: Diameter - q parity- --9a ❑ p arest u� T -- ---- _ -�- Distance from ne b ldsn9 Distance from nearest well-------------- ___ _______________ ______ Privy. ---- -- -- - ❑ Distance to nearest Oat line----------------- ---------------- ----- - ---- -------------- - Remodeling and/or repairing {describe --------------------------••--•------_ _=----- I hereby certify that I have prepared this applicatioSan Joaaui hL calkle tht andHealthdone District� accordance with San Joaquin County ordinancetate laws, and rules and regulations of the q I _ (Owner and/or Contractor) (Signed ------ f '7 l!----- � 1' ) p (Title)1e ---------------------------- -------- -..._.------ By: --------------------------------------------------=-----------------------_--------- -------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on.reverse side). FOR DEPARTMENT USE ONLY = - DATE--------------- r ---------- DATE--- K-- -��--!'`_-=------------------------------ APPLICATION ACCEPTED BY---------------------- ------- ------ ------- - REVIEWED13Y -------- ----------------------------- DATE--------- ------------------------------.-------------------- BUILDING PERMIT ISSUED -------- ------------------ - - - Alterations and/or recommendationst____----------------------------------------- ------------- ----------------- ----- ----•-------- ------------------ ------------------- ------------ ---------------- -- -- ------------ --•--- -------------------------------- ----------- _ ------------- 1 Date-- ------ - - ---- --- ------------- FINAL INSPECTION BY-------- ------ -------------------------- -------------------------- - - - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haatiton Ave. 300 west Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-59 3M 3-'63 f.P.0 D.