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FOR OFFICE USE: G h"=� ----------------------/--, Permit No. . (� / APPLICATION FOR SANITATION PERMIT ------------------------ ------------------- p p } (Complete in Duplicate) Date Issued __ __________ _ ____� ------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to consfiruct and install the work herein described. r This application is made'in compliance with County Ordinance No. 549. 1 4 � ---,6:-4-------- ------------ - ------------- - ----------------- ---- --------- . � " JOB ADDRESS AND 'LOCATION...."Z._�-�-�:---ti � -� Phone._. - Owner's Name-_. --�-: - y' ____________________________ ------------------------------- -----------------------___----..--_. Address----- ----------6._-------- -- - ---- •----------_______ � ----- Phone-------------------------'-_-_-.-_-_-_-.-_-_- _ Contractor's Name--.-- C_W- I t Motel Other ❑ Installation will serve: i Residence Apartment House ❑ Commercial ❑ Trailer 'Court ❑ ❑ Number of living units: -_I.--_ Number of bedrooms '�� Number of baths __�-_ Lot size ___. 1 s Private ❑ Depth to Water fable 1-0- ft. " Water Supply: Public:°system Community system ❑ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ (�, s NFHA/VA: Yes No ❑ Previous Application Made: (If yes,date....................) `No ® New Construction: Yes o E] TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool Permitted if public sewer is available within 200 feet.)` .-F I Y Distance from nbarest well__ _h6- f -. Distance from foundation__ _Q_______._.M Septic Tank: Dista �________- - Liquid t h g �Z Capacity..ga ---- o. of compartments---- ---------------�Size� X -� -X- Li uid d N7i + { � 11---------- N, Disposal Field: Distance from nearest well_T�{WL9., Distaan' a from foundation_.-._E__O_- � _ Distance to nearest tot line---_-.--__-_. �1 I'y Number of lines .__ ----------------- -- - Len th of each line- - _ _--!$.$S_ - _.Width of trench___.____._.'____ .Depth.of filter materiel----1$ .............Total length-----I- 71------------------ - Type of filter niaterial��_.-�C�C3_s✓ � - Seepage Pit: Distance to nearest well__________________.Distance from foundation_,__ _____- .___.Distance to nearest lot line____._-______.._ Linin' material t_�-y --.Size: Diameter------------- --------"Depth..........................'------ I ❑ Number of pits-:------------------ g I Cesspool: Distance from nearest well• _. ._ " -Distance from foundation--- ---------------Lining material----------..___-----_______.____----- r I De th------------ ---=-- --- ------ -- Liquid Capacity gals. J ❑ Size: Diameter---------- -------------- P ------Distance fromsnearesf building----------------------------------------- Privy: Distance from nearest well----------------:-__-__- 1 ❑ -------- --'------ -------------------------•---------------------------- Distance to nearest-]of line_______________,_....__._-.- , irr .----- I--------------------- ------------•----- --------------------- Remodeling and/or repairing (describe):---------------------------------- ------------ --- ) I. l--------------•-------,---•----: ---------- --- -------- -: - ------------------------------ " ----e----•------------ } ' -------------------------- -----=------------------------------------•----_--- ---------------------------------_------------------------ I hereby certify that I have prepa d this appli tion and that the work will be done'in accordance with San Joaquin aunty ` ordinances, State aws and r les and r guWio the San Joaquin Local Healtk District. --------- ------(Owner and/or Contractor} -------- -- --------------- ""-------------------" ------------------------- t (Signed)y. - --- - ----_ - ,I - ---------- --"------- ---------------=-------------(Title}--"-- --"----"----"- --- --' " --"---"'- -•-= ---- --------- By: "--""-- B '--------------------- -- ------ ------------------------------------- %- [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed an reverse side}. FOR DEPARTMENT,USE ONLY } -11 ----------------'-------------------------- '----- DATE--- "— lv- ------------------- -ACCEPTED BY_ r 1 # DATE------------------•---- -- --------------- ----•--------- REVIEWEDBY--------------------------------- ----=------ t -- DATE---------------------------- ------------- -------------- BUILDING PERMIT ISSUED-----------=-------------------------------- Alterations and/or recommendations:............... ......___._--.'--_- -- --------------------=-- F �-"r ----------------------- -------------------------------- - --- --------------------------=---•-------- __________________________-----_______ _ .-_-_-...._-___._____.___..____-___-__._. _ ..__.___,-__.._ v --------- --------------- r: .---------------------- FINAL INSPECTION BY:..- 1 �'y Date_..�Z.. .�_�.�P,S t SAN JOAQUIN LOCAL HEALTH DISTRICT `'14—) 1 t-4205West 9th Street 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street Stockton,California Lodi,California Manteca,California Tracy,California Er. 4 REVISED 8-59 3M 3•'53 F.P.ra;