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VUR UFFICE USE: --- --------------- ----------- ------- ----------------- ---------------------------- ----------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------- ...... --------------;----------- . (Complete in Duplicate) ------------------------ All.' 6 m ------------ ------ --------------------------------- ------------- ----- This Permit Expires 1-Year From Date Issued Date Issued by made to fl- 0�7- 1 Application is here the San Joaquin Local Health District for a permit to construct install the wo rK herein described. This,annI;r�.A+; A n with Count Ordinance No. 549. E a JOB ADDRESS SND LOCATION, P , I A I -- ---- ---- ------- Owner's Name --- - - -- -- - ------------------ -------- Phone------------------ Address------ ...... ----- -- - ..... - --- ---------- ---------- ------ -----------------:-----------_1-------------------- Contractor's Name----------- ---------- -- -- --------------- ------------_--------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑E] Trailer Court -Motel Other'E] Number of living units: J--- Number of bedroomsum____.Number of baths Lot size ------- Water Supply: Public f system E]- 'Community system rivate E] De Water Table -------- ft. , 0 Character of soil to a depth of 3 fee4 t: Sand 0 Gravel [] Sandy Loam�/C,,� Loam E] Clay E] Adob; 0 Hardpan C1 i Previous Application Made: (If yes,date____________________) No El New Construction: Yes,E] 'No 0 PHA/VA: Yes [] No TYPE:OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet�)— Septic Tank: D;stance from nearest well-____-_--.__---_Distance from foundation__________ _____Material--------- ----------- ❑ No. of compartments--------------------------Size------ _---------------- -------Liquid- depth----------- Capacity------------ V" - ---------- Disp 1'feld: Distance from nearest well--- Distance from foundat;on-_ --------- --- ......Distance to nearest lot line---------------- Number of lines______--___--.___ --- -----Length of each line------ Width of trench---- .-Type of filter maferial--- --- 1-t__ &--,-.-Depth of filter material--------�ff--------Total length_________________ __ ----------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation---------- -------.-..Distance to nearest lot line-------------- ElNumber of pits--=:7------------------Lining material---- i;------------------Size"�-DiYffi&er_---------------------Depth---- --------------------------- Ces"SI3661- J Distance'from "tance'from-foundation-------------------Lining material_.___.------ Dis ❑ S;.z'e: Diameter. i-------- Depth.- --------------------------------------------Liquid Capacity------------------ -------- gals! gr Privy: Di;fanc"e from nearesfwell., ------------x-------------- -----------------Distance from nearest building----------------------------------- Distance to nearest lot-line----__-------- -------------------------------- I ------------------------------------------------ --------------------K---------------- Remodeling and/or repairing (describe)--------------------_----------_- - - ---------- 0 ZI -- -- - --------------------------------------I-------------------------------------------------- ---•---------•----__:------------ -- - ------------------------ ---------------------------- ------------- ----------------------------------------------------------------------------------------------------------------- --------------- I ------------------------------- ----------------------------- ---------------------------------------I------------------------------------ --------------------I----------------------------------- --- -------------------------- ------------------------- ---------------- --------------------:------------------------------------------------------------------------- -- ------ - --- ----- I hereby certify that I have prepared t * application and that the work will be done in accordance with San-_Joaquin---County ordinances, State klaw ' dd rules and reg tions of the San Joaquin Local Heal District. [Signed)-------------------- e --- - ----------------------- -- --- ---- ------ 210-11.1 ------------ -- -------- --------J��/or Contractor) f . .............. --- - -------------- `___{Title)------- -- ---------11------ V*----- -------------------- ......... ......plan, showing.size of lot, location of system in relation to wells,E�� -- - - ------ uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--,/,2P 0 ---- ------------- DATE----./-----/_W REVIEWED BY------------' DATE------.-------------------------- ------ BUILDINISSUED_:_-_____________________________-------------- -- ---------------------------------------------------------------------------------------- ---------- ----------------Z7 G ERMIT ---------------------------------- ----------------------------------.- DATE----------------------- - --$ Alterations and/or recommendations----------------- r ecommendations:------- -------- --------------------------------------------------------------------------------------------------------------- -------------------------------------------------- -------------------------------1----------- ------ ------- -------------------------------------------------- ---------------- --------------------------------------------- ---------------------------------------- --------------------------------------------------------------------------- --------------------------- -------------------------------------------------------------------- ------------------------------------------------------------------------- -------------- ---------------------------------- ----------------- -------------- --------------- ----------------- ------------------------------------------------------------------------:-------------------- ---------------- --------------------------------------------------------- ------------------------------------- ---------------------------- ------ RNAL INSPECTION BY:... ....... ................ Date.... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hozolton Ave. 300 West Oak Street 724 Sycamore Street 205 West 9th Street Stockton,California Lodi,California• Manteca,California Tracy,California VS 9 REVISED B-59 3M 3-'63.F.P.CCI.