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FOR'OFFICE USE:.' ----------------------- ---------- ----------- --- APPLICATION FOR SANITATION PERMIT Permit No. _.71---- . ----------------------- ---- --------------------- (Complete in Duplicate) I/ """._..-- �f ` ------------------ ------- = --- --- ---=--------- -- This Permit Ex fires 1 Year From Date IssuDate Issued ed -'-- i Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L CATION Owner's Name-- /rife-�- /�/,, fit/�l� 119+7e/Y Phone--------------------- J iiXy Address �1_� D/1 j -------------- Contractor's Name_ . ^- - - �---� �7.- '--------------- ----------- ------- ---------- --------------------= - --•--- Phone�fh 1P/..;7------ Installation will serve: Resid ce Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ } Number of living units: __J--- Number of bedrooms Number f baths x�t of size ""-" - ap�, Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table "_-. ft. r � Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ S dy Loam E] Clay Loam ❑ lay El Adobe Hardpan E]Previous Application Made: (If yes,date................. ..] 'No New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I � t Septic ank: Distance from nearest well-_�_""fl.""Distance f om foundation____,�t�_".--___.Mater al_ -;, *6_69� ____________ No. of compartments--__.---- Size___-- " --__ / ` �---• , -�:/--fl-----Liquid depth ------ - ----�-----CapacitY--�ylrr�- �+ / -""-"-"-Le gth of each-line_"" p�" -------- " D'stance to nearest lot line_" .-"""_. D,sposal field: Distance from nearest ell-- __ ...".Distance from foundation.--_"_ -------- Type / p - Widfih-ofi�trench--" -""-- Number of lines f - t .. 7 e of filter material_ Y Q�"". _-De th of filter material ------.----.Total length---- 7 f --------- -- r Seepage Pit: Distance to nearest well `'Distanca from foundation_- """ ___"_--___Distance to nearert lot.lina-.""-" ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------- ----.Depth---------------------------------� Cesspool: (.Distance from nearest well-----------------Distance from foundation--------------------Lining material--.---_I _ --.-----._,.-- ------------ � Size: Diameter- r De-"th:."'_T-- ;s,�-- --- -�'Liquid:Ca 'acitY------------ t9a1� Privy:' Distance from nearest-well---------------------- p . I Distance ,from nearest building--------- ------------------------------ Distanceto nearest lot line-----. -------------------------- ------------------------------------ ----------------------------- Remodeling and/or repairing (describe):-_----------------------"_.------------------------- a' ----------------------------------------------------------------•- ---------------------------- •----•-- --------------; --------------=-------- ------ ----------•- -------- -------------------------------------------------------- --------------`------------------ -----_----------------------------- -----------------------------------------"---------------------•---------------------- ,_ -_w_ -_------„ '-----_.:- =---------------__------------ ---------- I hereby certif that I have prepared this application and that the,work will be done in accordance with Sans Joaquin County ordinances, St s, and ules and regulations of the7.San Joaquin Local Health District. [Signed tQi '---------------------------------=------ (Owner and/or Contractor) ---- -- -----------•---------------- ---------- -------=------ ---------------------------------------------------- Tale [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side]. t k FOR DEPARTMENT'USE ONLY APPLICATION ACCEPTED BY ------------- ----------------------------------- ---- ------ DATE--------- ------- REVIEWEDBY------------------------- ---- ------------- --- - - ------------ ---------- - -- -------------- r ---- bA7E_..”�.--.��'".-�- -----�--•---------------- . BUILDING PERMIT ISSUED- ----------•-------- ------ DATE--------- ---------------------------------------- -_ �._ _ _ . Alterations and/ar reco _ . mmendations:-____...-.:_ -"" -------------.------------------------ --------------------------- ......... - - -----------•----------------------------------------•----------------------- ---------- FINAL INSPECTION BY----------- ----- --------------------- --------------------- Date----- ----------- ------- - - --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Hamilton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stotkton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3"'63 F.RCO.