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FOR OFFICE USE: _____________ ___f�__ ________________ APPLICATION FOR SANITATION PERMIT Permit No. .. ... ._:.......... ---- '" 1 - --ll----------------- (Complete in Duplicate) f Date Issued ------------------------------------- This Permit Expires 1 Year From Date Issued ...... ..%lL � Application is hereby made to the San Joaquin Local Health District for a perrni+to construct and install the work herein dscribed This application is made in compliance with County Ordinance No. 549. 1.j E , j LEEJOB ADDRESS AND LOCATION---N----T'!J��.T.,I-AI�---}.(.7_Y--�--•--- "'?-i!-la•�-J'-/�----�1.!�-•-l.�'..--��•-(7--_- .-.-•x•s•'� Owner's Name E } W11. . ---->---'- ---------------------------------------- Phone..---•---•-------•--..... . .. _... _ .c x----•. .... ..... Address _ .. t4_nT _.C . ......------••..............................•-----•-•--•--------------•--------- Contractor's Name........tjlw`fg�... ••-----•------•-••••-- .............................................. Phone................ Installation will serve: Residence e Apartment House Ej CommaL Trailer Court [I Motel ❑ Other ❑ Number of living units: -.%.... Number of bedrooms .__ _. Nnmier of baths /---- Lot size .....OrI5...x..=3:3v:.............. Water Supply: Public system ❑ Community system I-] Private �epWfo Weer Table/5- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam�Clay Loam ❑ Clay❑ Adobe ' Hardpan ❑ _ ., Previous Application Made: (If yes,date--------.-___--__--) No slr New Conuctio�t., ' es &No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fe Septic Tank: Distance from nearest well......Distance from foundatiovvcmh ®� No. of compartments......��-----------Size----3-�•-/__�J�_,•-•Liquid_dept h....-------------Capacity.... 6045, Disposal Field: Distance from nearest well-_5Z)-_----Distance from foundation...19.....,DAi to cyto nearest lot line... j�- Number of lines-__--_-.�....................Length of each lin _.._.... .__.__ .�J........ or of�trench... ' .-.:.`/�..,��- Type of filter material..RO_444.......Depth of filter material.___.f .............Total length._..... ,.....,r.2:5... Seepage Pit: Distance to nearest well----------------------Distance from faiundation....................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------,x------=-- ----------------._ •------------Liquid Capacity----------------- ......gals. Privy: . Distance from nearest well_______________________------------------------------------------ ,,._Uistance from nearest building ❑ Dis • ---- �,., .,....,...,d.� �. _ t ---- AID6 Cl RemgdefiFig and/or repairing (describe):_____ AI _ l 6TA1- ------Q ,........................... lt.h ._1 = ? uTTT --------e-F---..H,F.-A-1-TIS---.-1?l4---..' '-- - ------A-5-..JASTA 1t.-O.....D�.. Po -- :---15- Fpft---,A,1 !xT-7 >... (�5 .-.... . . I hereby certify that I have prepared this application and that the work will )fie,dQno imAra Bence with San Joaq _CoWjfy' ordina s and rules end I ons o the $ n negs..5#ete lip! i+....-49-quim.l ocal..Neal#IsJ�s# ..y..-.. . .:_::. _.. ..r) _ s rt f (Signed) ------------------------------------------ -----(Owner and/or Contractor) f (Plot plan, showing size of lot, location of qs o aj relation to wells, buildings, etc., can be placed in reverse side). FOR DEPARTMENT USt 'C) 1LY APPLICATION'ACCEPTED BY....`-j"r%r1" ,tom,.________________._ ....... DATE...../�....:/g'- ........................ REVIEWEDBY............................................................................................................................... DATE........................................................... PERMIT;ISSUED..............................................................-..................................... DATE............................................................. Alterations-end/or tecommead'atiris-------------------------- - ---------------------------•--------------------------------------...---•---•--....---------•-•--•- •... 1 ........................................-------•-•--------------------------------------------------------------•----...------------------•--------------------•-------- =.......................................... ---- •-• ......................................... . .............. ....... . ........... ................._. ... . .... ....... ...._. -_-------... ''- .,.-�..,,.......�—.:.... ._. .. .ter FINAL INS Date. ` .-----•. •------•-- ? SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wed Oak Street 124 Sycamore Street 405 West 9th Street ~ Stockton,California Lodi,California Manteca,Cod, "la Tracy,California ES 9 REVISED 8-89 8M 5'61 ATLAS i