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FOR OFFICE USE:-- ---------------------------------- --------- ---------- APPLICATION FOR SANITATION PERMIT Permit No- ---------------_------- ------------------------------------- 2:�,_ 4rk. (Complete in Duplicate) 4 Date Issued ------------------------------------ - --------- ---- This Permit Expires I Year From Date Issued Zf-71; ---------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 LOCATION-----------------------------91-f-'30---------- -0-------- ------------------ ---------------------------_...... ------- Owner's Name------- ---- -----(------------------ ------------------------------- -- ------------------------------ ----- Phone- Address------_---------- ----------- --- -----------N-1-------------------- --------------------------4----------------------------------------#-7' Contractor's Name--------------------&_&u.�'_ ------- ------------------------------------------------------------------------------------- Phone---------------------------------- Insfallaiion will serve: Residence ja--Apartment House E]I Commercial [] Trailer Court L) Motel J-] Other E] 1k %, ''Number" -.11 57��1) I m '�r 00m, � ` 'of baths -------- Lot Number of living units-. ---/--- Nut ber o`f'b drsize ------ -------------- 4-- 7-7- Water Supply: Public system ii�C_0mpity system E]3-Private Fj Depth to Water Table ------- ft. ' I Character of soil to a depth of 3 feet:i. Sand E] Gravel 0 Sandy Loa'm [] Clay Loam E] Clay E] Adobe Er"�Har�dpan 0 Previous Application Made: (if yes,date___.___._,.__..__:_) No 171 New ,to�'iistrucfion: Ye-sE_j-_R_o7r'FR`A/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) " Septic Tank,-,;- Distance from nearest well_________________Distance fromiG'undafion___, ---------Mafetial�-- ---__I---- --------- --------- No. of compartments__ ---------------------Size------------------ i---------Liquid dbpfh------------- -----------Capacity______----------------f e R '! - 1. t / i. I- I X D;sposal i6lcl-' Distance from nearest well............:D�stance from I fou'nclation-A9- - Dist6nce to nearest lot line 5 h"_ %Y ----------Width of frenrh..-. 4.- ------ Number of lines_____;.____I ---------- Length of each I ID T -of filter,material. -Depth of filfe,' af8i",-�I� Totai,lengtk:____45 ..Y-pe ----- --- ------------ -------------------- ........ 4 . ./,1�.* � I ..- il� , - isfance to nearest lot line -ndatron._-- -I �__/_Y_l_I�3N 17 Distance f6--rF66res we -------- s an"ce from Seepage Pit: t�Ell _AZ U-Meer of pits tk - F__1------------- -------I------Lining maferia6_1_ _1_l7a._ Size: _17 A&A- vt Cesspool: 'Distance from, nearest well--.----.--------=_Distance from,foundation.-.-----------------Lining material_____________________*_-_._____- Size: Diameter------ -------------------------------Depth----------1_11_d�---------- ------ - -------------Liquid Capacity-- .-------------- ------ gals. (a Priv Distance Dist8nce,from!nearest well__-____________________________ ____.-Distance_fnrpm, _Reai-e_5f_bu'(Ldir)_g------------------------------------- L Ell Distance to nearest lot line----------------------------- ------------------ ----------------------------------------------- ------- -- ----- 'be): .... ---- Remodeling and/or repairing (des 7r -------------aw- _7�----- --- --------------------------------------------------------------------- ------------------------ ----- ------------------------------------ -------------------------------------------------------- .......... ---------- ------------------ -------- e,21'xx-&-t ---- -- --------------------------------------------- ----------------------------------------- ------------ - ------ ----- ------ ----- - --- -- ------ I - hereby certify that I have prepared epared this application a'ilh)at the work will--be--done in accordance with County` ordinances, State laws, and ru 6 d regulations of the S Jo ocrath District. 'a' f ,�q.in L . ...... ---- -------- ----- - - - --------------- ----- - ------- -- - ------- (Signed)--------------- ---------------------------------------Owner and Contractor) ica - --------- By:----------------- ------------------------------------------------------------------------ ------- -"-------------(Title)----- ------------ ------------------- .................. f o (Plot plan, showing size off location of system in relation to wells, 6uildiT,, eic., can be placed on reverse side). FOR DEPARTMENT USE ON!_Y,\� APPLICATION ACCEPTED BY--- ------- -----------------------•- // DATE--- T----------------- REVIEWED BY-_------------------------------ -------------------------------------------- ------- -----------. DATE------------------------------------------7----------------- - -------------------- BUILDING PERMIT ISSUED_.------ --- ----- Z ----------- DATE------------------------------------------------------------- ------------------------ - Alterations and/or recommendati0 ns----------------------------------------- ------------------ ------------------------------------------- ---------------------------:.......... ------------------------------------------------------------ ----------------------------------------------------- ...... 1 - -- ----------------------------------- --------------------------------------------------- ------- Z --------------- �?-- --------- Z_ ---------------------------------- ------- ------ r ---------- ----. ---- ------ ---------- -------------- ------------------------------------------------ ------- ----I----------------------- ---------------------------------------------- ------- 4- FINAL INSPECTION BY ......... ------ -------------------------------------------- Date-------- /Zll�------- --- -------- ------ -------------------------- ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazollon Ave. 300 West Oak Strbet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,Cc i ornia Manteca,California Tracy,California f V.6 9 REVISED 8-59 3m 363 F.P.Cri.