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FOR OF Us . ------- ----------- '--3----.- VAPPLICATION FOR SANITATION PERMIT Permit No. __1.4�. -/.. ---- ---------------- -{Z -----'-- lr� (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issued / 3 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 Ordinanc�No. JOB ADDRESS A DATION--------,�r�__ -� Owner's Name... _ ,r �/ ------------------------------------------------- ----- - Phone ol Address ------------------------------------------------------------------------------------ y� �+ Contractor's Name Phop€ , - Installation will serve: ResidenceApartment House ❑, Commercial E] Trailer Court ElMotel [3Other ❑ � r Number of living units:..__ Number of bedrooms(;-Z-- Number of baths _/_ Lot size _, �1___ _•��,1�_____________________ ; t � , Water Supply: Public system ❑ Community system E] Private Depth to Water Table Z____ ft. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeZr Hardpan ❑ Previous Application Made: -{Ifyes,date--------------------) No ❑ New Construction: Yes ❑ Noo FNA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION~AND_SPECIFICATIONS: (No septic tank or cesspool permitted if pu6lic sewer is available within 200 feet.) c` k:_ Distance from nearest well-----------------Distance from foundation------------.-------Material---------- ------------------------------------- No. of compartments--------------------------Size---------------------------- ---Liquid depth------- -------Capacity---------- ------`---• s ei,po,al Fie'fd: Distance from nearest Distance from foundation__Z—A--f_-_-.Distance to nearest lot line__--,-'_______ ,r Number of lines-------- ------ ----- Length of each line-___-_ _S ..__-_,._Width of trench-- �-�-a_-_---._____.-___ Type of filter material_ __ A Depth of filter material__/_9___--__.__._Total length_______________________�4_,_____- r r � Seepa e Pit: Distance to nearest/well__,10�--_--___Distance f �m-�fQQ}}'�ndaticn_A,�•i ---__._.�s}anc� to nearest lot line__. ______ r Number of pits------/- _----------Lining material_ t --.Size. Diameter—_.2-. -. .--------Depth--- ------ Q Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------.----------------------._--. Uj ❑ Size: Diameter------- ---------------------- -------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------._-__---_---_-. r ❑ Distance to nearest lot line------ ---------------------------------------------------------------- -------------------------------------------------------- Remodeling and/or repairing (describe):----------------------------------------------•-------------------------------------------------•-------------------•--------------•--------------------- "f ---•--------•----------•-••----•---------------------•--------•---------•-•----•-----------------------•------•---••-------------------------------------------------------------------------------------------- L -----------------------------------------•-------------- ----------------•-----------------------I•-- -----------................---------- ---•---•--- -------------------------------------------------------------------- ----------------------------------------------•--------•------------•----------------------------------------• -------------•------------------------------------------------------------------------------------------------- I hereb ce e tify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances t laws, and rules d regulations of the San Joaquin Local Health District. (Signed)-_ - Y. _- --- -- •---------- - ------- ----------� --------------------------------------------•-----------•----- Owner and/or Contractor) _ By:.- - ----------------------------- - - --- - -- -•.............• �...nr�,. = = (Title) - - (Plot plan, showing size of lot, location of system i " elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ DATE_______________ _,�------__________.__._ REVIEWEDBY---------------------------- -------------------------------------------------- DATE---------------- --jV------------------------------------- BUILDING ---------- -------• ---•------- BUILDING PERMIT ISSUED-------------------------------------- - - • D T Alterations and/or recommendation :__-__ _ -- -- •! --- ' ------------------------------------------------- ------------------------------------------ ------------ -----------------------•---- --- ------ .................... -------------------------------------------------- •--.-- FINAL INSPECTION BY:.------. --1 - ---------------------- Date--------- ------------•------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E-Ha:ellon 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 31A 3-'63 F.P.CC.