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µ 1-UK UFFiCE USE: r ------------------ ----- -------------------- _____- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) ' This Permit Ex ires i Year From Date Issued /// ----------------------- ----- Date issued 7`., lw t. Application is,hereby made to the SanJoaquin Local Health District for permit to construct.and install the work herein described. This applicationis made in compliance with County Ordinance No. 549. 1 JOB ADDRESS AND LOCATION.____ ' 1 � Q --------------•--•. Owner's Name GLX"e � 4P f -_1'i.... . /�� t* --=---------------------- - --_ - _ - _-----._.:Phone---- TT �-�7. Address !"' ---R-i _Q._lrI----------------------------------------- ------------------------- Contractor's Name----.. ----------------------------------------------------------------------- . --•---- ------ Phone_ ��-� Installation will serve: 'Residence p� Apartment House ❑ Commercial f r r ice' ¢ s ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __-[.___ Numben of bedrooms _.,.7__ .Number of baths -- _ Lot sizef,._ Water Supply: Public;system f` [❑ Community system [] Private Depth to Water Table _��?_r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ SandywLoam. -Clay Loam ❑� CJay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if pub lr'c*sewer is available within 200 feet.) - _ Septryi�c Tank: Distance from nearesfi`well` :-d �Ih�Distarrcej�from found �h- _-_!--:__,--_ ! - No. of compartments:___. - ._--_--__--Size .--, L __Z($ Li ----- Liquid de th___.____ o J - i q t I?. '�`-----�--=----Capac�ty_.LpZ.�_.---�Q1, Disposal Field: Distance from nearesfi well--5-0-M)-4,Distance from foundation.-/Q1►t111�.Distance to nearest lot line__ rI1+i-,►� : Number of lines -0-------------- --- Length of each line--------L4. ----- ._..Width of trench_.____��1�',-- Type of fitter material-sep.._�o!�R._Depth of filter material ------- .1 t I . . R Total length - Q -------- -=------ Seepage Pit: Distance to nearest-well-------------_---------Distance from foundation___.._.____--:------Distance to nearest lot line__.____.--_____-- ❑ Number of pits__#---- ------Lining material--------- ------..Size: Diameter.------------------------Depth-------- ---- V Cesspool: Distance from nearest well -_-Distance from fo'undation____________________Lining material.___.__.___.__-______.____---- I 'i ❑ Size: Diameter --------------------------- Depth------------------------------------------ ------Liquid Capacity--------•------------------gals. Privy: Distance from nearest well__w___ ____ _________________ I - - ______________Distance from nearest building___---____.____.._____-- El Distance to nearest lot 14T,� ' _--_--- '" -' <- j:' ---------------.. Remodeling and/or repairing (describe:- _ _� ...... v .f -------------- ------------------------------1-AV------- .rtt-w: ) � = - -�g __aft 5��'r 5 P e .� l { ---------------------------- ___________________ _______________________ _______ - - _ r ________________________________________________________________rr ________._____.-_______._______.-__________--- .-_______ -_-________.__»__-____--__-______--_____-_____._.____ I hereby certify-+hat I have prepared this application and that-the work'will be'done in.accordance with San Joaquin County ordinances, State laws; r les an r. ations of the San Joaquin Local Health District. ' r { F4 (Signed) ! A --- - - -. - By:----------------- ------------------------- -------- - (Owner an r Contract ------------------------ -------------------•- {Title) or --- -------------------------- ot plan, showing size of location of system in elation to wells, buildings, etc., can be placed on reverse side). i 1 FOR DEPARTME T USE ONLY APPLICATION ACCEPTED BY---------- n - - - --------- -----i. C� --- -- DATE- - ------- . ---------- REVIEW ED BY ---- ------ ------------ - --- DATE- ------------- ------- BUiLDING PERMIT ISSUED----------------------- ---------------- DATE - ------------------------------------------------- Alterations and/or recommendations:_ _ - -_[�0�- ----, -_- pL►*}rf0� �� _ --------------•------- -----=----- -------- ----- _____________________________ i FINAL INSPEC N 'BY-.'- Date-----------„/,. __'/`` _ 6.' 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lod],California Manteca,California f Tracy,California ES•4 REVISED 9-59 F.P.0 D.2M 6.60