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' -FOR ' Z. / ,1 ------------------------------------------ - ___ _ _--:_. APPLICATION FOR SANITATION PERMIT Per No. .1............ ..... -------------------------- / (Complete in Duplicate) Z 1�-(--- ---- ----- -- Date.Issuad�---- --- ----------------------------------------------------- I 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 described. This application is made in compliance with County Ordinan No. 549. JOB ADDRESS AND OCATIO .............................................. -•----- Owner's Name......--- ------------( ----- 1.. Phone..............................•..... Address........f/. .,�5._._. .r:.....- wle.netlaxlt Contractor's Name................... . _ Phone,/ d�.dQQ.._ .......0 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ... Number of bedrooms 9- Number of baths Lot size .,1. 'e..' .,1 ............... Water Supply: Public system ❑ Community system 9?1-*Plrivate ❑ Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes [rlo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic sewer is available within 200 feet.) 09 Septic Tank: Distance from nearest well •- ----Distance from Sizel yi� fou9ndation-JA...•--....M rjal-&---•---•-•...- .9� No. of compartments----�--------------- , Liquid depth______ &/ _______________Capacity,..0.1 � p ' Al'Disposal F' Id: Distance from Weare, well____________ __.Distance from foundati ry.,,lQ�.....,�Distance to nearest�lot ling..........:..... Number of lines...... __ ______ _ __Length of each line.. Q.^ O^�Q.Width of trench.....s¢.y.............r.... Type of filter material.si. -_-Depth of filter material..___'.........Total length.....................a.�z 0........ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits----------------------Lining material.......................Size: Diameter........................Depth................................. Cesspool: Distance from nearest well.................Distance from foundation....................Lining material..................................... ❑ Size: Diameter--------------------------------------Depth-------------------•--------------------------------Liquid Capacity............................gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building.......................................... ❑ Distance to nearest lot line.............................................................................................................................................. Remodeling and/or repairing (describe):......................................................................................................................................................... ---------------------------------------.................................-•-------•-•-•--•-------•----••--------------•----•-•---------------•----------••••-----•------•---•----•-----••-•••------------•-••-------•-------- I hereby 0;`r—fi4 that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St-de ws, and rules and relglations of the San Joaquin Local Health District. (Signed)----------- - -------•---••• -----If•-.- •••- ----Pin ---- ............................ nor and/or Contractor) By:. ...... ---- -• .... �------•-----------(riitle)....��-------------- ----- -------------- (Plot plan, showing size of lot, location of systeelation to wellf., buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.......L--1--T tt<s-.......................................................------- DATE.......I �- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE--•-------•----.....--------------.........---•--•-••-••... BUILDINGPERMIT ISSUED..............................................................—....................................... DATE............................................................ Alterations and/or recommendations:--------------------------------------------------------•-----------------------------....----•-•-----------••--•---------•---......--•---•---...-•--•-•--•-- FINAL INSPECTION BY:.-- ------------------------------------- Date-- Z ) ' ' ................................................ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-89 RM 6-61 ATLAS