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=AOR OFFICE UE: "" 4 APPLICATION FOR SANITATION PERMIT Permit No. ............. . t.. ------------------------- (Complete in Duplicate) �I , g;i --------- -----------•- � -'Date Issued -----•----� _ ______ ---•----- ---_._ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct end install the work herein described. This application is made in compliance with County Ordinance No. 549. j JOB ADDRESS A�NR LO ION...3..�-(I---------- Owner's ----•-- ;i �J _ �t!_s[" .------- -----•----__------------------P_hone.. Owner s ame.._________.`______ _ - Address----------------- ----------•------------------ --------------------•--....---------------------------------•-•-•-----------••-- Contractor's Name-------------- Phone----------------------------------- .�. .---•-•------------------------------------------•---•--------....------------••--------•-•------ Installation will serve: Residence JF�,Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ .___ Number of bedroorrfs-3--___ Number of baths ...L Lot size -.__.�0.-6. Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ FA A ' Previous Application Made: {if.yes,date---_"______________) No 2tNaw.,Constructi�_n:_ Yes es❑�..❑. �.-_H�/V : Yes ❑ No El TYPE OF,SINSTALLATION_AND_SPECIFICAT.IONS: � .s - (No septic tank or cesspool permitted if public sewer is available within 200. feet_) - Septi, Distance from nearest well-----------------Distance from foundation....................Material................................................. No. of compartments--------------------------Size--------------------------------Liquid depth ------- ---------Capacity P ".__Distance to nearest lot line.--b......... W pis osal Nield: Distance from nearest well-- - __-._Distance from foundation..___._U' .? 7 4, Width of trench---------------•---- -•-----.--.-- �} x Number of lines-------...: "- � f_ g _ r� le 4_ ' Type -- _-- -- Length th of each line-rial __j-X----- --.Total ken th-----•-•--- --- r, foute 9 ! a. �- l. T e of fitter material._.."" � 4---De th of filter mate Seepage Pit, Distance to nearest well----------------------Distance from ation_.•:__.....-__-•___.Distance to nearest lot line..._-._.____..... ❑ Number of pits----------------------Lining material__..-----•-------------Size: Diameter-------_-�__f_-.----.Depth--.---------•----------------.... Cesspool: Distance from nearest well_________________Distance from foundation........-----------Lining material------------------------------------- El Size: Diameter_ Qepth----------•-------------• -------------------------Liquid Capacity----------------------------gels. privy: Distance from nearest well-------------------------------------------------Distance from nearest building---_-______-•______------______--____-.--- ❑ Distance to nearest lot line----------------------------------------------------------------------- ' ""-- -- -----" -- ---------------- Remodeling and/or repairing (describe):________Q� - - z'` •-•-----• -----•--------"-•------------------------•------------------------•----•-"----•---...---•--------..-....----------- ---••---"------------------------------------ _______ ----------------------•-------••--------•----•----•----------------"-•----------.----••--•--•-----•-""-----"--•-._....-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. z 1 ... ---------------------------------------(OwFnrand/or on tractor (Signed)----_----------------------•-------- ---- -------------------------------------------- � - -----------------•---- (Plot plan, showingszeoflot, locatonofsystemin relation to wells, buildings, etc., can be placed on reverse side). FOR,DEPARTMENT USE ONLY ) APPLICATION ACCEPTED 3y............ ---- ------------------------------ ------------- DATE --- -------------------------- REVIEWED. BY ------ --- -- ------ •----------------•---• DATE i BUILDING PERMIT ISSUED-----•----------------------------------------------- ------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:..------------ ------------------ -----.....-----••---------------•--•---••-----------------------••---------------------- --•-------"-"---•---............................................................. ------ --------"- --------------------------------...---•-•---•--•-------•----•-- ---- -------------------------------------------------- ----•--•--------- --------•------•- ....... .. ..... ...... Date ._._!." '----- -C-- ---------------------- FINAL INSPECTION BY._.... L/ SAN AQUIN LOCAL HEALTH DISTRICT 124 Sycamore Street 205 West 9th Stroll 130 South American Street 300 West Oak Srnef Y Stockton,California Lodi,California Manteca,California Tracy,California E8 9 REVISED 5-99 2M 5'61 ATLAS �-