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r, j FOR OFFICE USE: _. APPLICATION FOR SANITATION PERMIT Permit No. � r. ------ - ------ (Complete in Duplicate] > �3 This Permit Expires 1 Year From Date Issued Date Issued ---161 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 A OCATION------ _ � , '-- -------••-------------------------------------------------------- ` � t'/ Owner's Name � a /.1--_ ----- - - --- --- Phone Address-----_-_-------•-----• _c ------ Contractor's Name------------ -�-- -------------- Phone Installation will serve: ResidencgM- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Ej Number of living units: .-�lumber of bedrooms__ Number of baths _ .�LOt size --- __ --'�-C9` --------------------- Water Supply: Public system �munity system ❑ Private ❑ Depth to Water Table(p.. __ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Cl� /OVrA ❑ Adardpan p Previous Application Made: (If yes,date___________---------) No ew Construction: Yes El No : Yes ❑ No Ej___ 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 from foundation-----------------___Material---------------.__.___._________________________- a �t$�/��✓ o. of compartments----- - --------_A-----Size--------------------------------Liquid depth-----------_-------------Capacity----------------------- Disposal Field: Distance from nearest well.._. ..........Distance from foundation../.0__/_____.Distance to nearest lot line---5,7__/____ [ � Number of- lines______________ �� �__________________Length of each line___- �____-- -_________.Width of trench-_r.�____ �JSr/�✓�,� pe of filter material____1__�_y-1_e�Depth of filter material_____ Total length___- �311_f________________________ ------------ Seepage it: Distance to nearest well-, an from un tion__ _ _i_.Distance to nearest lot line_._______.._ umber of pits____/______.______Lining materia__ �.�- .__.S' e: Diameter__ .,3._l_..___Dept&___ UW' Cesspool: Distance from nearest well_______._____.,_Distan undation--------------------Lining material___._ _.____ j___________. ❑ Size: Diameter-------------------------- -----Depth-------------------- -------------------- ------Liquid Capacity_---------------------- gals. Privy: Distance from nearest well_____________________________.________._____Distance from nearest building-__---____.-_-_-____-________.4_____: ❑ Distance to nearest lot line-------- -------- --------------------------------------------------- -,------------------------------[-- -------- --------------------------- R ------ Rmo -- -------- - ----------•-----a---------- 0 e -------------•------•-------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------.------ — F — ----- --------------------------------------------- --------------------------- ------ ----------------------------------------------------------------•----•-------------------------------------- I herebycer '#y that I have pre ared this application and that the work will be done in accordance with San.Joaquin County ordinances, S at a s, and r, an r ulations of the San Joaquin Local Health District. _ (Signed)--- __ ___________ __ _ _ t (Owner and/or Contractor) By:------------------- Title - -------------------- (Plot plan, showing - of lot, location of.system in re ation to wells, buildings,.etc., can 6e,placed on reverse side). FOR DEPARTMENT USE NLY APPLICATION ACCEPTED BY--------- --------------- -----------------------------------------------W DATE-------- Y_ r w REVIEWED BY -- ---------------------- DATE BUILDING PERMIT ISSUED-------------------------------------- -----------------------------------= DAVE Alterations and/or recommendaf ons:__----111 �8 _1 A_____- ---•.---------•-----------'- --------------------------------------------------------------------------------------------- ------------------------------------------------------------•---------------------------------------------------------------- ------------------------------------------- ------- ------------------------------------------------------------------------------- - •------------------------------------------------------------------------------------- ------------ -------- --------------------- -------------------- --------------------------------- ------------ -------------------------------- FINAL ------------ :-J-3.1------ --------- FINAL INSPECTION BY:.------. - ----------------- ------------ Date--------------- -- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 west Oak Street 124 sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVI550 6.58 aM 3-'63 F.P.Cp.