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1-UR OFFICE USE: ---------------------------------------- ----------- ---- ------ ---- ------------------------------------ --- --- APPLICATION FOR SANITATION PERMIT Permit No. ------------ -:----------------------------I------ .1 (Complete in.Duplicate). ----------- ---------T--------- ------- ------- ---------- This Permit Expires I Year From Date issued Date Issued ---- 2—0 2-dN-0—0,3 Applicati6n is hereby made to the San Joaquin Local Health District for a permit to c6nsfruct and install the work hergin des bed. This application is made in compliance with County Ordinance No. 549. 4' JOB ADDRESS AN LOCATION A ---- -- - Owner's Name------ - ------------ --- ----- t-o--- -------------------------------------------------------------------------------------------------------------------------------------------------- - -------- ----------------- -------- ------ Phone - Address _ -----------1-7•-- Contractor's --------- - Name--__".--_-- ----------:_---- Phone ---------------------------------------❑ ---------------- Installation will serve: Resid;nce ISd Apartment H6use 0 Commercial E] Trailer Court F Motel b Other ❑ e Number of living units: ,----- Number of bedrooms 0.- Number of baths __/_ Lot size ----- Water Supply: Public system Ej %Community system El Private Depth to Wafer Table ft.. Character of soil to a .depth of 3 feef:"*,.Sand E] Gravel E] Sandy Loam [] Clay Loam E] Clay E] Adobe Hardpan E] Previous Application Made: (if yes,date -------------- No E] New Construction: YesNo El FHA/VA: Yes 0 No E] TYPE OF INSTALLATION AND SPECIFICATIONS: . X ,1,.-(No septic tank or,cesspool.permitted if,.pu6lic sewer�i sAvailable-within 200.feet.) 4. Septic Tank: Distance from nearest we4_1 0------- Distance from foundation--J-40! M f -------------- No. of comparfrinents-.-c'?—--------- S i I e 7-------Liquid dep.fh - - ---- - C apacify-4;Z-an Diksl Field: Distance from nearest well S-4......tbisfance from foundation--4/4,--i----•� Pistance to nearest lot line3d... .. _-C/a.Width of trench---0 Number of lines__-_--"__ ---- -----Length of each lffle&49:�146 7 ..- Type t L -filter mafe,ial---/,ff.."__"__--Total length----------------- e of filter ma eria Depth of Seepage Pit: Distance to nearest well-__-------------_---Distance from foundation---------_ _-__--___.Distance to nearest lot line--------------_. j i F-1 Number of pits------'---------------Lining,material--------- -----;------Size: Diameter-----------------------Depth----------------------------- Cesspool: x Distance from nearest well---_---*'".__--__Distance from foundation------------------- Lining material--.---_---_------_--_--------------- Size: Diameter---------------------------�_�'` _Depfh 414 . ----? -I - - ---------------Liquid Capacity----------------------------gals. y-FrT,-y- r _57-s--r- ---. .. -=� ;_�-- — _.. Distance from nea es+.well------------------ -------------------------------Distance from nearest building--------------------------------- ------- ❑ Distance to nearest lot line-_"' -Remodeling and/or repairing (describe]:---._.. _0- ------- --- ------------------------------- 2 x. �11. ------------I------------ ------------------------------------ ----------------- -------------------------------------------------------------- --------------------&----- ----I--------------I---------Xr----------------------------------:---------------------------------------- y ----------- -- ----------------------- V ---------------------------- ------ -------i--------,-*--- ------------------------*, 2-------------------------------------------------------------------------------- ---------------------- ---------------------- -------------------- �- ---------------------------------------- ----------------------------------------------------------------------------------I--- I re6y ify that'1 have prepared this application"and that the woill�will :be done'in accordance with San Joaquin County ordinances,erat J:.laws, �,-�d�`rules,_P ; e4q regulations of the San Joaquin.;-L;cal Health District. ..... 1 1, _01 Z d -/(S;gne ----- ---- ------ ---------- --- ---------------------------------------- and/or Contractor) Fwner By-------------------------------=---------f Qi -------- (Plot plan, showing size�of lot, location -------------------- -------- .............. ;f_sys+emjn`reIati91r+o wells, buildings, etc., can be placed on reverse side). .0 oe FOR DEPARTMENT USE ONLY APPLICATION ACCERTED_BY- -= - ------------------/ DATE------------ --------------- ------------ ---21- REVIEWEDBY---------------------------:-------------- -- --------- ----------------------------------- DATE BUILDING PERMIT ISSUED---------7-- ---- DATE. ------------- -- - --------- : ------------------- ---------------------------- --------- DATE 4KAlterations and/or recommendations:--------- .-%, ----------- ------------------------------------------------------------------------------------------ -------------------------------- ------------------- ------------------------------------------------------------------ -----------------------------------------------------------------I-------------------I---------------I--------------------------- ------------------------------------------- ------------------ - --------------------- ----------------------------------------------------------------------------- ----------------------- ------ ------------------- --------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ ---------- ------------------- ------ ----------- -------------------- ---------------- ----------------------------------------------------------------------------------------------- - -------------------------- -------- ----------- - - FINAL INSPECTION BY------------- --- Date------- --------- 2 -- -- -------------- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Mant"Or California Tracy,California ES 9 REVISED 13-59 3M 3-63 F.P.CD.