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FOR OFFICF USE: ` { - ` Permit No. -------------- r APPLICATION FOR SANITATION PERMIT -- --------------------- ------------------------------- (Complete in Duplicate) Date Issued ---. --------------------------------____ This Permit Expires 1 Year From Date Issued Application is hereby made to the San-Joaquin Local Health District for a permit to construct and install the work herein descried. This application is made in compliance with County Ordinance No. 549. .�-Iy—y-�_ F ----------------------••---••---------•---•- JOB ADDRESS AND LOCATIO ...... 1_ "�_...!!!- l ----- -- = ............... Owner's Name________. .• ----- - - - -------- ------------------------------------------------------------- Phone--40--•-_2_-1-L--7 -7 Address----------_--- . ----------•--- ------ --------•.............................................................. �,dclress Name... -- !� ---•-- Phone------------------•-----.---------- Installation will serve: Residence gr-"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ t Number of living units: _L. Number of bedrooms .-� Number of baths -Z--- Lot size - `� . ----------•------------•-- pt Water Supply: Public system El system ❑ Private �e th To Water Table - Character of soil to a, depth of 3 feet: Sand ❑ Gravel I-], Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Uk-<ardpan ❑ Previous Application Made: (If yes,date____________________) No [ New Construction: Yes ❑ No [?I--'T-HA/VA: Yes ❑ No Pa— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sstic Tanks Distance from nearest well-----------------Distance from foundation--------------------Material______.-_________•._____-_- ------------------- tjAf&l4,f No. of compaetments---------------------------Size--------------------------------Liquid depth--------------------------Capacity.----•------••----••-•- Disposal Field: Distance from nearest well ----------------Distance from foundation____________________Distance to nearest lot line---____---__..._- Aum Sf Number of lines-----------------------------------Length of each line-----------------------------.Width of french----------------------------------- •n---_ ---De _Total len ------ �L ` Type of filter material..-----------------------Depth of filter materia{______________________ th------------------------------------ g Seepage Pit: Distance to nearest well__/tIpf _..__Distance fr m fou.dation_._. _Distance to nearest lot line--?49...... Diameter__. _-- Dept h- n �---- -----•-----•---••-- Number of pits__..1------- Lining Size Cesspool: Distance from nearest well---------_-------Distance from foundation--------------------Lining material______-..-_____-______...------.-._._ } ❑ Size: Diameter--- l-------------------------------Depth-------------------------------------------------•-Liquid Capacity----------------------------g8s- 1 __Distance from nearest buildin Privy: Distance from nearest well g ------------ ❑ Distance to nearest lot line----------------------------------- ----•-•---•-------------•---------------------- --------:-- r q o g •} ------ e --- - ! ^ c� --------- ' ! Re deling rid/or repairing de c ibe : _______._ _ -- --"'� '�--tom- -- ---- -----_-- - - -- -- -- - -- ----- ' c4do &^�14 y I • 9 n c�rtry fh�t�d�h'a�f pared As p a ha o ill�90 ccb�d'a n "itireS n a oun ordinances, State laws, and r les and regulations of the San Joaquin Local Health District... , . s ----- er-a* ar Contractor) (Signed) _ ) _- Title.----- - - - -- --- --------- -- (Plot plan, showing size of lot, location of system in relation ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- f -------------------------•----------•----- DATE... =f --Z - REVIEWEDBY. DATE--------------------------•---- -•------------------------ BUILDING PERMIT ISSUED ------... - - DATE ------------ Alterations and/or race mendations:_. r ]j,u _ 1laC a �' "` 1 ------- ------ --- -------- ----_. ------ ---------- - ---__..----- - i --------- -- -- _ �� . < ._.... ------ --- ------------- FINAL INSPECTION BY:... ----•----- Date------- ------/.3--• .___A�:�-----•-------•-----. ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I 300 West Oak Street 124 Sycamore Street 305 West 91h Street Stockton,California I Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5.62 ATLAS