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FOR OFFICE USE: ----------------- ----------------- -------------------- APPLICATION FOR SANITATION PERMIT Permit No. ._.1_22.;V, (Complete in Duplicate] :I Date issued Application--- - hereby made to a San Joa'su�eLo Permit Expires 1 Year From Date Issued Qc{ _ 2a ca r 17 - pp y th q cal Health District for a permit to construct and install the wor ereinl described. This application-is made in co `pliance with County Ordinance No. 549. JOB ADDRESS AND CATION. Glr1 __ ___ - -�------ .- =--�r------`----''�'��' �-�j G Owner's Nam e- ..>.. .,.------ -- _ �-.-,_ �-- _�._ ------- Ph -----•- --- one Address �.. ... c��ls__ _ _ k__:_:_ ------------------------------------------------------------ •-- Contractor's Name----- --------- Il------ - ------- ------------ -- ---- ---- -------- ---------------- --------------.._- Phone---------------------------------.j Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units- ----- Number of bedrooms ,4____ Num�4epth .baths _ Lot Iii e�._"- / ------------------- Wafer -_ Water• Su I . Publics stem Community system private to Water Table ---___-" ft.PP Y' Y ❑ Y Y ❑ t Character of soil to a depth of�3 feet: Sand ❑ Gravel ❑ Sa y Loam Clay Loamf❑ lay-❑ Adobe ❑ Hardpan 0 Previous Application Made: (If yes,date--------_-,-.-_._..) No iNew Construction: Yes No d.' .F.HA/VA: Yes ❑ No 0 :I TYPE OF INSTALLATION AND SPECIFICATIONS- 4_ No septic tank or cesspool permitted if public sewer is available within 200 feW) '" - - 5e ti ank. Distance fr! 3 om nearest well"---_J�__a_-.__Distan�ekrn foundaftion__._1Q-__.:____.Mate�al._._...__ •e_._..__: P •, X �-.__Liquid de th__._.r� No. o£ com artments._..._. _Size.___XV_.. p _Ca acit n + f rl Dispose field: Distance from nearest well-_-__,�0_.i...Distance from foundation_--__+��---------Di-stance to nearest lot line.5 __. -� Number of lines------------ -- Length of each line-----7Q--....... -----Width of french----_�Z__-------------.----.---- 1.1 Type of.filter material_ ___-_Depth of filter material__-f ___---___Total length------- Seepage Pit: Distance to nearest well--------------------."Distance from foundation------___------Distance to nearest lot line___ _.__---- 6�.,,� � El Number of,pits----------------------Lining material---------------------.-Size: D'ssameter------------------------Depth----------------------------- �lfl'1• Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ' ❑ Size: Diameter-----------------------:----------- rDepth------------------------------------- --------------Liquid Capacity----------------------------gals. Privy: _Disfance from nearest welL____._._-_.-------------------------------------Distance.from gnearest building----"-"""""_._"_-_--_-___---_.-_-..----.-. p ❑ Distance to nearest lot line ----------------------- ---------------------------------------------------------------------------------------- ------1-------- Remodeling and/or repairing I(describe)---------------- --- ---------------------------------•------------------------•----------------•------------------------------------•-------- -----45:1F i I�: A. p. ---------------------------------------------------l----------------------------------- --•---•------------------------------------------------------------------------------------------------------------------------------ I hereby certify th hav an e prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law , rules and regulations of the San Joaquin Local Health District. ----------------- ---------------------------------------------- --�d or Contractor I (Signed) = J - _ _`V.=" --- _---�--- -- •itle — �.... -" (Plot plan, showing size of lot,�locationfoyrem i .relation to wells,.buildings, etc., can be placed on reverse side). i� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ -, --------- ---------------------------------------- DATE--'_{K._ +3 _(IeV- ---------------------------------- REVIEWEDBY---------------------------------------------- ----------- -------------•----------------------------------:----------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---1--------------:---------------------- ---------------------------------------- ------- --------- DATE-----------•--•---------------------------------------------- Alterationsand/or recommendations-------- - ----------------------------------------------------------------------------------------------------------------------------------------------------- -•- ----------------------- -------- -------I.---------------- --:--- - ---------------•--------------------------------------------------------- •-------------------------------------.------------------------- -------------------------------------------------- -------------------- ----------------------------------------------------------------------------------------------- ----------------------------------------•------------ ql FINAL INSPECTION BY:-- - Date...7_._----�-��--------- -------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i 1661 E.lfazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISEO 8-59 3M 3"'63 F.P..CC.