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FOR OFFICE USE: ----- - Permit No. -------•---------•- --- f r Y �7 --------------------------- d APPLICATION FOR SANITATION PERMIT [Complete in.Duplicate) r Date Issued/ -------- ------ --------- --------------- --------- This Permit Expfres 1 Year From Date Issued -------------- - - _ M Application is hereby made to.the San Joaquin Local Health Dice strict for a permit to construct and install the work heresn described. This application is made in compliance with County JOB ADDRESS AND LOCATION.___-9749 -- ------------------- Phone------------------------------------ y Owners Name-------- y --------------------------•--------•----•------ Address I one......•.......------------•----- -•------------ -- - - Contractor's Name_____________ _ Other ❑ Installation will serve: Residence &- Apartment House ❑ Commerual ❑ Trailer Cow# ❑ Motel ❑ - Number of baths _ --- Lot size -$p-- Number of living units:___�__ Number of bedrooms e to Water Table 4 ft. Water Supply: Public;system �ommunity system [) Private [IpDepth Adobe gg/Aardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy'Loam ❑ Clay Loam ❑ Clay E] 'Construction: Yes ❑ No ®r'FHA/VA: Yes E] No 4;— Previous Application Made: (If yes,date----------- -----) No `I ew TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted-if public sewer is available within 244 feet.) J�f( m Maeal_---- -_Distance:from nearest well-----------------Distance oCapacity.---_-------------- Septic Tank: Sze quid de th,_ No. of compartments--------------- f Distance from foundation_.�ls�"----.----Distance to nearest lot line Vis ----- from Field: Distance from nearest well �- / Width of trench_�Z---------------------------- �_ .__._ Length of each line---- ---- =' � Number of lines------- -- - � • �! 1.Total len th....��----=------------------------ /t;l �� De th of filter material__- ,' g Gf Type of:filter material_ __ - P �,, P--_-_.Distance to nearest'lofi kine fads--.---•- ,�' ------Depth_ ---------------- See age Pit- i Distance to nearest well__.._-°'+^ in - Oteaal e f fes° Sloe Diameter- !e of pifs �----- -- __ g �s� Distance from nearest well------------------Disfiance from foundation..---._...-_.__._--.Lining material____..___._-.___----- als. Cess�d -Di a -Liquid Capacity----------------------- --g ------ r� } ❑ � Sze: Diameter----------------------------------- -----------------•----------------- -� i - - -------- -_-----Distance from nearest building-- Privy: Distance from nearest well________________ ❑ Distance to nearest.lot line---------------"------- ---------------- ----------------------•-------•- -- ----------------------- Remoddling and/or repairing (describe):------ --------------------------------------------------- ti ----------------- ----------------- -----••------ -------------------------•---- ::-----•----•------ :-------------------------- -------------------------------- ----------------- � I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. - I -- --�r Contractor) ----- ----- (Signed) i ----------------(Title)- •f��-� RY -- -- L re ation to wells, buildings, etc., can be p aced on reverse si a). [Plot plan, showing size of.lot. location of syste FOR DEPARTMENT USE ONLY DATE--------- _.A -_ APPLICATION ACCEPTED BY------- -- ---------- :DATE REVIEWEDBY --------------------------- -------------`---------------------- DATE------------------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------- ---------------------------- ------ ------- --------------------------- ----- ---------- Alterations and/or recommendations--------------- ------------- -------------- - == __: ----------------------------------------------=---•---------- ---- - ---------- x: ---- ------ = ------ -------------•--------------------- -------------------`---------.-' / Date.---- FINAL INSPECTION BY:_._ - -x-- �� ---- SAN JOAQUIN LOCAL HEALTH DISTRICT l124 Sycamore Street 205 West 9th Street 1601 E.Haselton Ave. 300 West Oak street Tracy,California Stockton,California Lodi,California Manteca,California a �S 9 RFVISED 5-59 3M 3-'G3 F.F-CD.