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APPLICATION FOR SANITATION PERMIT Permit No. .___�.-.__. �" (Complete in Duplicate) Date Issued --- Applica;ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. t This application is made in compliance with County Ordinance No. 54 ' JOBADDRESS AND L CATI N-------- 040-------- ----- ------------------------------- --------------------------------------- -------------------------------------•-• a Owner's Name---- ------- --- --- - ------------------------------------- Phone------------------------------------ ------------------3�7 ��' �J' �'� .... �1 lv �p ... Contractor's Name-----_---------=----- AV-1 4.1t --- --------------------------------------------------------------= Phone�J.# � ------------- Installation will serve: Residence Erl'partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ .Other ❑ / i X Number of living units: J., - Number of bedrooms �_ Number of baths .f..__ Lot size ---_��'S--,X d________________________ _ Water Supply: Public system M---C'ommunity system ElPrivate ❑ Depth to Water Table _� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑ Previous Application Made: Yes ❑ No g�lNew Construction: Yes [�o ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) � Septic Ta k: Distance from nearest well /Distance from foundation__ Q----------Materi ��L, ,_Aa__:__ .. l ---------- No_ of compartments------ap--------_-----------Size--S_ '---xv Liquid depth------�/��_------Capacity..- ------ - Disposal ield: Distance from nearest well-_! /._Distance from foundation__ ._____._:Distance to nearest lot li __S___________ Number of lines--------�--- --Length of each line-- -Z5- --------------Width of trench---- •---- -`------------- Type'of filter material__'�!_� ___Depth of filter mater3aL....._Af--._....Total length-----------------9�^_________________ � �� r � See pag it: Distance to nearest well.l._wr`n .- Distanc ' om� fffundation_._ .? ______.Dista,i to nearest lot line-----` ______. pp Number of pits----- --------------Lining material_ D . _.Size: Diameter----0713----------Depth....;Fd_�_.__.___-_-_____ rV Cesspool: Distance'from nearest well--------------_Distance from foundation-------------------- Lining material-------------------------- .0 ____-___-______--_-_---_-.❑ Size: Diameter------------------- ----- - ----------Depth---- - -------------------------------------- -----Liquid Capacity------------•----------------gals. d Privy: Distance from nearest well-------------------------------------------.-_--..Distance from nearest building-__-___________________-___-________-_. ❑ Distance to nearest lot lire- ----------------------- --- -------------------------------•-------------------------------------------------------------------------------- Remodelingand/or repairing (describe) ------------------------------------ -----------------------------------..............----------•-•--•----------:------------•--•----•----•----------- ---------------••••••• ------------------------•-•-----------------------•-•••-------------------------------------------------------------------•---•-••--------------------------••----•--•--------•---•--•---------------- ------------ ----•--••---------- --•--------- Iher y certify that f have prepared this application and that the work will be done in accordance with San Joaquin County ordinan s, tate laws, and u es and regulations of the San oaquin Local Health District. '_- Owner and/or Contracto't (Signed) := Lt� ----------- ---------------- / ) r gY --.---- 1._ (Title) (Plot plan, showing size of lot, location of system in relation to wel�, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY ------ --- ----- ----------------•-••--- PATE ` REVIEWED BY-------------------------------------.---- -- ------------------ _ DATE Z�---------- --------------- BUILDING PERMIT ISSUED--------------- ------ -- --- DATE ------ --- ----------------------- Alterations and/or recommendations:------- -------------- --- -- ----- - ---- --- ------------------------------------ FINAL INSPECTION ......BY:------- -----------------•--------------- Date_._.`�7.'^ S� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Was+ Oafs Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-u' 14544 ATWOOD