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/a G F9,R OFFICE UAzz_ l _._______--- APPLICATION FOR SANITATION PERMIT Permit No. ... t (Complete in Duplicate). --------- I This Permit Ex ires,1 Year From Date Issued Date Issued _______________ __-__- 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 Ordina ce No. 549. JOB ADDRESS A CATION_______ ,�----------- -`f` `` d - --- ------- ----•---------------------------------------- Owner's Name---' -- el -� 14r �1 64 --- Phone------------ Address--------------------- .- ---- '� ------------------ Contractor's Name-----------! - ------ ---- •--------- --------------------- Phone----------------------------------- Installation will serve: ResidencepartmentHouse [I Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: / Number of bedrooms Number of bathsf ly Lot size -- ---------------- f Water Supply: Public system ❑ Community systemPrivate [] Depth to Water Table;wj'ft. it l Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand LoamE] Clay Loam E] Clay [I Adobe lardpan El Previous Application Made: (If yes,dclte_----------_--------) No New Construction: Yes 9-<o ❑ FEMA/VA: Yes P-- 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---- ----__-ypistance from foundation__. d__"__._.Material_��-.��/��---"-- No. of compartments_ . _________ -.---Li Liquid de th____ `` J q P ----- --------Capacity-,ld: Distance from nearest wefl.__--- -------_Distgance from foundation-- -:--`. Distance to nearest lone-_%5_'/ Number of lines_______0,__ ------ ---"-.-.---Length of each line___ ___- _-Wi Width of trench.ry Type of filter material___VAC-_Depth of filter maternal _ _______Total length _,/_S_V_ i Seepag it: Distance to nearest well_______l__:_.___ _Distance from fo}�ndation__1P_........ tante to nearest lot line__ OF / Number of pits____.. ---- ----Lining material__r0-G./(__---.Size: Diameter__ _---_---_--Dept k- ... �_!--------------- Cesspool: Distance from nearest well________________Distance from foundation-----.--------------Lining material-------------------------------- ❑ Size: Diameter--------•-----------------------------Depth----------------------------------------------------Liquid Capacity- -------------------- -----gals. Privy: Distance from nearest well------------------_----------------------------_-Distance from nearest building__-__..._"_-___________________.__-_-._._. "I ❑ Distance to nearest lot line_____________________________ Remodeling and/or repairing (describe)______________ ____ --------_ 0 --------------------------------------------------------------------------------------------------- --------------------------------!�---- -- - ------------ ---------------------------------------- -----------------------------------------------------------------I----------------•----•---------------- -----•------------------------------------------- ---------------------- ----------- -------------•--•---------------------------------•.-----------••-----•--------------------------------------------------------------------------------------------- Y I hereby?cel-_' Xfl repared this application and that the work will be done in accordance with San Joa uin Countordinances, Se and regulations of the San Joaquin Local Health District.5i ned -- _____._____(Owner an /or Contractor){ 9 )--------- ----- -- -- --- ------------------------------------------------------------------------------------- -[Plot plan,.showinq_socation of sys+em to relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------------"---------------------------- DATE------------ REVIEWEDBY------------------------------------------------- --------•--. DATE------------- ------ ------------------- -- --- - ------- --------------------------------------- BUILDING PERMIT ISSUED DATE - --------------------------- -- Alterations a d/or recommen fio s:-----------------------=-------- ,t rd �'O rY �� -- ------------- -----., ---------------- - ------------ -------------` - F€NAL INSPECTION BY---------- -- ------------------------ ------------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.gq. Jff f