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FOR OFFICE USE: --------------------------------------------------------- fr --------------------------------------------------- APPLICATION FOR SANITATION PERMIT' Permit No. ...... -------------I-------- ------ - ------- ----- - ------- `D'afe is!�G&d -------------------------------------------------------------- This Permit Expires I Year From Date Issued P&� V �� Application is hereby made to the San ijoaquin Local Health District for a permit to construct and install the work herein described. This application is mad, in ,,pj',, with County Ordinance No. 549. i made with C, P' L C 4� 7 4#4v7 .... 1 ------------------ ---------------------------------------- JOB �DDRESS AND LOCATION ------- -------- ------------------------- Owner 'Name 1.,_ W1- ----------------------- --------- Phone-.:- s I. .. . ...... ------------ - ------ ---------- ------- ----- ..... ------------------------ -----------------------------........ Address---------X-1110 -------6_� ..�1- 11 --------------------- ----------- --------- Contractor's Name --- --- ---- Ka ---- --------------------- ...... Phone............. ------------------- Installation will serve: Residence q&/Apartment House ❑ Commercial'E] Trailer Court E] Motel E] Other Number of living units: __L_"INumber of bedrooms ..`,<Number 61f b'afks ___/__ Lot size ---------------------------------------- Water Supply: Public:system E]. Community system [-I Private U6/"`Depth to Water Table 7.0--- ft. Character of soil to a depth of 3 feet:i Sand E] Gravel Sandy'I Loam El' Cla;,'Loam El Clay Ef-"'Aclobe 0 Hardpan 14 New Construction:'Yes El No FHA/VA: Yes F] No 0 Previous Application Made: (If yes,date---- ---------------), No TYPE OF INSTALLATION AND SPECIFICATIO' NS' . X (No septic tank or cesspool permitted if public' sewer,_ii available within'200 feet.) Septic Tank: Distance from -- nearest-well-------------------- [jistance from�':fo'undafion-------------li,_.M-aterial---------------------------------7�-------------- ❑ No. of comparfinerifs -- -- - ---------- ---Size---------------------------- ------ ----------- ----r Capacity...;------------------- Disposal4ielcl; Distance,from' nearest-well----------- ------Distance from foLriclation-------------------Distance to nearest lot line----2�� Ed Number of lines' -----------------------Length of"e`ac�Iine___'_",—>4PF_.' :Width of trench.- '>— " W -----------i------- --------------- 0------------ Type,of filte-r—m'%terial- Depth of filter material------ Total'length--- 14 yep Seepa Distance from fo nclation--- -------------Distance to nearest lot line----------------- '96� Pit: Dista to nearest well.-.---/0-0--- T 'o .Number o� p;fs.!_1__/----- -------Lining Size: Diameter.......;��"......De ------------------ Cesspool:" DiSfance from 'near`est well_------ - --- ,-Distance from foundation--------------------Lining material--._._----.-_--_-.---------_--------. —'fh `7 ------------------ ,r Size, Diameter--------3----------------- `..Depth......`�,%-—---------------------- Li�6 id Capacity----------------------------gals. I - Privy 91 E Privy-, Distance from nearest.well_----------------------------------- ---- ------Distance from nearest building--------------------------------------- Distance to nearest lot line__-_-_ -----------------------------------------------------------1_:--------------- -------------------------------------------------- - -- ----------- ---------------------------:-------------------- Remodeling and/or repairing (describe(: - -------------- -----------------------------------------------------------—--------- lesc eI:-------- ------- ------------------------------4------------------------- ---------- --- ----------------------------------------------------- ------ --------------------------------------------------------- t -------------I-------------------------I------------I-----------_1------- ---------------------------- -----------------------I-------------------------- ---------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Las,'and rules regulations of the San Joaquin Local Health District. re (Signed)---------- ---- -- to-4� z- ...... --------------- ----------------------- ----------fE)WW5r and/or Contractor) By:__ ---------------------------- - ------40-1- --- -- ----------- ----- -------------------------frtlel--------- -------------- - --------- - ....... ------------ --- (Plot plan, showing size of lot, location of system i?rla+i[,n to wells, buildings, etc., can be placed.on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__,' ,�_ _ 1�el� --------------------------------------------------------- DATE__0l`.-.3_._�__. ---------------------------------- jREVIEWED BY------------------ -----------------f---------------------------------------------------------------------------- ----------.. DATE-----------•--------•---- --------•--- BUILDING PERMIT iSSuED-------------I----------------------------- ------------•------------------------------------------.- DATE------------------------------------------------------------- Alterations and/or recommendatiorils-------------------------------------------------------------------------------------------------------------------------------------*------------------------- --------------------------------------------------- --------- - ------ --- ----------------------------------------------------------------------------------------------------- --------- --------------------- ----------------------------:-------- ---------------------------------------------------------------------------- --------------------------------------------------------------------------------- fi ---------------------------------- ............. ------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------- ......................................................... ------------------------------------------------------------------------------------------------------------------------------ ---- - -------------------------- FINAL INSPECTION - ---------- Date... ------------ -------- ------ -------------------------------- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 0-59 3M 3-'63 F.R00.