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FOR OFFICE USE: ' i --------------------------- ------------------ -- - - JI _ --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. 1�/ljlJ --------------------------------------------------------- (Complete in Duplicate) --------------------------------------------------------- ' This Permit Expires 1 Year From Date Issued Date Issued _______ Application is hereby made to the Son Joaquin Local Health District for a.permit to construct and install the wor-LEerein described This application is made in compliance with County Ordinance No. 549. CAZo 1 r JOB ADDRESS AND LOCATIONIVIVETRE�----- .------_----�-. LV . CJFF:_S1=-7x-_ °i- ICL. DE Owner's Name_______________ j :............ . ------------------•--- Phone-----------=---------- Address............ f ----•-•-1 Q--. ....... # tl :� �� -------------------------------------------- Contractor's Name----Qk1lnrP__ .,4 -----------------------------------------------------......... Phone------------------------- --------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: _)_____ Number of bed rooms�_,Number of baths .1..___- Lot size ---404- II r,.,, i'7^i t ; Water Supply: Public system ❑ Community system ❑ Private Depth Water Table - Z?ft. Character of soil to a depth of 3 feet: Sand[] Gravel ❑ SandytLro m$ clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: {if yes date___..__'""__ _._} No,� New Construction: Yes�o ❑ FHA/VA: Yes ❑ No k, TYPE OF INSTALLATION AND SPECIFICATIONS: I; (No septic tank or cesspool per;itted if public sewer is available within 200 feet.) -•. Septicfrom Distance from nearest•wel� JDis#ante fofu n�ton__"1�______.Meal__.-1 _C-8JFZ�7 v}`� No. of compartments- _ __ ___Size q pdCapacity-_-. Q , Is a m.'-foundation-----/0....._.Distance to nearest lot line-_-. :_~ Disposal Field:- NumbeDistancr of linesfrom e�rest well_ __ Distance fr achy line_...._ 570 - - ------_---._Length of a � --- -------.Width of trench------_-a'L - • Type of filter material._-.- - + _Depth of filter�material------- g___.----Total length____________________5(0------------- Seepage --_-- ---.See a e Pit: Distance'to.,nearest,well.___Ia_10 Distance from foundation_____ _ Distance to nearest lot line_____ � Deptht r Number.of pits--____--(.---------Lining matanal. �G. ;--- size: Diameter-- --... ---- ------.:.1 l k I tZ Cesspool: Distance from nearest well-----------------Distance from :founlation--------------------Lining ❑ material-----______.___----.._.____' Size: Diameter--- i ' Depth = ___ ____________Li Liquid Capacity ' a..ls... Privy: Distance from nearest well_________________-------------- ----- ._. _ -__Distance from nearest building____--__._________-_-•----------------- F1 -- --------- -"❑ Distance tot nearest lot line________ t - _ ___ -------------- --•----------------•-•----•------- ..--..-------------------------------------- -- Remodeling and/orrepairing•(�escribe}:- - ------------------------------------ ...-•--- ..----•--•-------------------------------------------------------- •-------•----------------------------------•---•------,--- ----•----•------------- ............---•...........= ---------------------- 4 t •-- - - --- - - -- ------------- --- --•-- ------ - --- ------ -- - ---- I hereby certify that I hayVprepared this application and that fhe0iwo ik will be done in accordance with San Joaquin County ordinances, St - .laws, and rules cid regale ns of a San Joaquiri'Local, Health District. - .s (Signed). '"" -r 1 -c- (Owner and/or Contractor) _. By:.: = - ------------------------ --- - (Title) - - :_Y----- _- ------------------------- . . (Plat plan, showing size of lot, location of system in relation to wells", ILuildings, etc., can be placed on reverse side). ' l FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1 1 4 ------------- -----"----------------------------•----- DATE-------- --- - ?__ '- -. REVIEWED;,BY:-=------------------------------------- - ----- `-------------- DATE--------------- - -- -------------------------------------- --------------------- BUILDIJSIG-WRM,fT - Alterationsand .. - V Tt _.__ r-- A ------------------- - - =------------•-------•-------------- ey . F—4Y 9 !- - - r ryr[ _..___- I --------- _______-______.______._____ ---------------------------------------- -____--_-__-__ ________________r_1..__-....-__.______.____--______-... __ _____-.______.-__.-.-____________.________.____--__.____._G______--._,.-.---------------_------ --------------------....._____.._....... r ____ _ _.__e___________ ----------------------------------------------------- ------------------------------------------.---------------------------.......... FINAL INSPECTI N B . __ ...... .'�.. ------ - ------------- Ei Date-•---1L/.r- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wort Oak Street 124 Sycamore Street 205 West 9th 51rea1 Stockton,California Lodi,California i Manteca,California Tracy,California E5 9 REVISED 8-59 2M 5-62 ATLAS i